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Old 09-15-2009, 10:03 PM   #121
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Which is precisely the concern many people have about relying on laws to force insurance companies to cover money losing chronically ill patients.
But doesn't "no underwriting" solve that? If your private ins co isn't meeting your needs, switch to the public option. Yes, we need transparency and rules to avoid "dumping" tough cases onto the public option (one complaint of private versus public schools, right?). But it sure seems to me that if it becomes known that your private ins co is going to "dump" you onto the public plan, they are going to loose customers.

To put the shoe on the other foot - if we hold the govt financially accountable, what assurance do we have that the govt won't cut coverage to the bone for chronically ill patients? And if we don't hold the govt accountable, there is no comparison to begin with.

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Old 09-16-2009, 08:56 AM   #122
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I've been trying to follow the health care debate and understand what is being proposed. Despite spending quite a bit of time reading online sources, it seems fairly difficult to get an accurate description of what is being proposed. (Journalism rant: I can find all kind of articles about who agrees with or opposes current plans and even who is in favor or opposed to which other persons ideas. What I have to look very hard to find are the actual ideas or proposals. Is "sound bite" journalism taking over the print world too. Ack.)

As near as I can tell (somewhat uncertain) the new proposal is all about who has to buy insurance, what that insurance must include (where the minimum coverage is pretty much guaranteed to involve the insurance company in every health care transaction), and what tax and/or tax credit scheme will be used to help some people who currently are uninsured buy this new insurance. People's tax credits would be paid directly to insurers in some cases. This is sounding less like "health care reform" and more like "insurance company mandates". There are also penalties for people who are "required" to buy their own insurance and for whatever reason don't buy the required kind. No wonder insurance companies love this.

I am not trying to make this into a political debate and I will wait until some more details about the actual provisions of the bill are revealed before making up my mind about supporting or opposing it. But I am suspecting that this is heading in a direction that insurance companies will love, but consumers may not be any better off and the entrenched problems with health care delivery, transparency of costs, rapid inflation of costs and quality of care will be completely unaddressed.

I wonder what would happen if instead we mandated HSA's for everyone, with taxpayers footing the bill to subsidize whoever needs subsidy according to the latest political machinations. If people were spending "their own" money (or at least real money they could see) perhaps many of the cost and transparency issues would address themselves. I doubt we will see anything like that in any version of the current plan.
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Old 09-16-2009, 09:31 AM   #123
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Yes. If you can afford it and desire it, you could buy "upgrades" (private rooms, etc). If I can live in a nicer house than someone at the poverty level, why shouldn't I be able to buy nicer coverage (assuming some reasonable minimums are met by the voucher)?
What is "nicer" coverage? You either need the medical service or you don't. You want everyone to have preventive care, to save cost in the long run. A private hospital room versus a shared room isn't going to be a big cost savings. Already insurance plans don't cover purely cosmetic procedures and rarely cover things like fertility treatments and abortions. The Cadillac plan usually means very low deductible and copays. So how much of an additional cost burden will those who are not covered by a large employer plan have to bear, especially if they are required to buy insurance? Dental and eye coverage? I suppose that could be the difference. But you want your poor to get that and medicaid covers it now, more or less. Right now it is the people who work for non-mega corp who don't get those benefits. I have never had dental and eye coverage and dont have any expectation of getting it.
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Old 09-16-2009, 10:01 AM   #124
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You either need the medical service or you don't. .
I don't think that your black and white view holds water in this case Martha. There are lots of procedures and tests where need, waiting time and frequency seem to be open to debate by qualified experts.

Of course, in a situation like the Canadian plan where there is a govt board that determines "what medical service you need or don't" there is much less debate and your interpretation may be more applicable.
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Old 09-16-2009, 10:44 AM   #125
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You either need the medical service or you don't. .
This is a horrible idea.

If I have a medical condition, there are usually many options for what kind of treatment could be used. Likewise, if I have an issue, not yet fully diagnosed, there are many options for what kinds of tests or treatments could be tried.

The idea that I will ONLY be allowed to use what specific medical service I NEED and not any optional services flies in the face of common sense. I had a doctor who tried to practice like that, once. He would advise ONLY a specific treatment that he considered the "standard" of care and would not consider any alternatives or possibility that there were other considerations, nor would he ever test for any other conditions once he had determined the "current issue" for my visit. I think his approach is completely wrong and I found him impossible to work with, so I changed doctors as soon as possible. I hope this quote has been taken out of context, because if this kind of thinking is any part of future medical care we will all be poorly served by doctors like my former doctor and care like tickmarks on a checklist.
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Old 09-16-2009, 10:47 AM   #126
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What is "nicer" coverage? You either need the medical service or you don't. You want everyone to have preventive care, to save cost in the long run. A private hospital room versus a shared room isn't going to be a big cost savings. ....
That's the beauty of a free market - it could be whatever some creative group offers that people decide they want to pay for.

Private versus shared room was just an example, I don't know what the cost delta is. I'm sure there are many others I have not thought of, but that's my point, free markets fill needs/wants, sometimes ones we don't even realize we have until they are offered. Another might be more flexibility of non-time-critical procedures:

A) Mr X, you since you paid extra for the Executive Level Plan, you can schedule your wisdom tooth extraction at any of these offices, at any time that is convenient for you.

B) Mr Y, you are on the basic govt subsidized plan. We will call you 24 hours in advance when we have an opening for your wisdom tooth extraction, be prepared to show up at the appointed time and place.

Or maybe two equally effective procedures exist, but one is more expensive, but can be done in a single visit, the other requires multiple visits. The Executive might choose (and have access to, since he paid extra) the more expensive procedure, because his time is money to him. And on and on.

And if no one wants to pay extra, there is no extra plan - it's a free market, with a govt admin plan as a back-stop. It just opens up options that maybe the govt "one size fits all" might not include.

I guess I don't see how these options add any burden to people who accept the basic voucher (if that is what you are saying).

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Old 09-16-2009, 11:03 AM   #127
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I will be as nice as i can be. good health "insurance" is not a right it is part of a pay package you get for working (part of your pay). so its something we work hard for. i would expect the guy who gets up in the morning drives 50+ miles to WORK to get better care then the guy sitting home watching TV Not Working. i hope this doesn't get zapped
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Old 09-16-2009, 11:13 AM   #128
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This is a horrible idea.

If I have a medical condition, there are usually many options for what kind of treatment could be used. Likewise, if I have an issue, not yet fully diagnosed, there are many options for what kinds of tests or treatments could be tried.

The idea that I will ONLY be allowed to use what specific medical service I NEED and not any optional services flies in the face of common sense. I had a doctor who tried to practice like that, once. He would advise ONLY a specific treatment that he considered the "standard" of care and would not consider any alternatives or possibility that there were other considerations, nor would he ever test for any other conditions once he had determined the "current issue" for my visit. I think his approach is completely wrong and I found him impossible to work with, so I changed doctors as soon as possible. I hope this quote has been taken out of context, because if this kind of thinking is any part of future medical care we will all be poorly served by doctors like my former doctor and care like tickmarks on a checklist.
My post was in reference to what a basic insurance policy should cover. Yes, I know that there are different treatment options and treatment options may very depending on your own personal situation, but that is not my point. My point is that a basic plan is not going to be that different from a so called cadillac plan. The term Cadillac plan usually was used in reference to low deductibles and copays, without dollar limits on coverage, not so much what it will cover. Now there are some states that allow very crappy plans to be sold, that I would find less than basic. Maybe they don't cover drugs at all. Maybe they put a cap on coverage per year or per illness. Maybe they don't cover pregnancy. These kinds of caps should not be in a basic plan. What is the point of the insurance if it doesn't cover the catastrophe and doesn't cover necessary treatments?

That said, I don't know that a plan should cover every goof ball treatment around just because some doctor likes it. If it isn't supported by at least some evidence, why should the plan pay? Like using chiropractic to treat allergies. Shouldn't be covered because there is no evidence to support that it works.
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Old 09-16-2009, 11:32 AM   #129
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The most "cost efficient" system any way you slice it is a single payer system. Only all the political leaders don't want to put all the insurance companies out of business. Any other attempt at a fix is a band aid, without true cost savings possible in the long term. There is too much money currently being taken out by the insurance companies not designated to health care. There are too many young people without coverage, cause they think they are invincible, and too many people using the emergency rooms for their health care, cause they can. Think social security. You probably don't need it when you are young unless you become disabled, but you pay it when you are young, so you have it when you get older and need it.

It appears as not enough people have suffered the wrath of the insurance companies, and until more are personally effected, we may not be able to make necessary changes.

My "fantacy dream" would be for every member of congress to lose their insurance with no alternatives but to try and buy private insurance for themselves and their family. A few years of this, and we would have a very speedy solution.

Yes... the most 'cost efficient' system when it comes to PAYMENTS is a single payor system... but that is if it works right... who thinks the government can run a cost efficient payment system

Also, having a single payor does NOT address the cost side... with almost all these proposals... they are just trying to spread the current costs among more people (let's make those young-uns pay into the system to support US)... now, you can have your single payor tell the docs and hospitals that they will not get paid if they do "X" or "Y"... so they will not do it and now you have rationing.... that is what people are concerned with the proposals.... that rationing will kick in big time...
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Old 09-16-2009, 11:43 AM   #130
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I will be as nice as i can be. good health "insurance" is not a right it is part of a pay package you get for working (part of your pay). so its something we work hard for. i would expect the guy who gets up in the morning drives 50+ miles to WORK to get better care then the guy sitting home watching TV Not Working. i hope this doesn't get zapped
As a country, we can make something a right if we want to.

If you have money no one says that health care should be free.

I know someone who was laid off in his mid 50s, he can't get health insurance as he couldn't afford COBRA and now can't get on the state's risk pool because he didn't take COBRA. He is looking for work and hasn't found it. So no chemo for him if he gets cancer?

Our country currently divides people into the worthy and unworthy for health care, in my mind in an arbitrary fashion. Some people have the right and some do not. In most states if you are poor but not elderly, not totally disabled, or don't have young children there is no health care program for you. You are not worthy. This is also true if you are working for an employer that doesn't offer health insurance and you can't buy or afford to buy on the market, or if you are laid off and can't find work and can't pay the premiums, or if you are homeless and have no skills to get yourself into the work force, or if you are partly disabled and just can't find work, or yes, even if you are just a lazy ass sitting on the couch. But given that there is no "dole" the number of lazy asses sitting on the couch fully able to work but not doing so because they just don't want to may not be too high, though I suppose they could be sucking off of a spouse or family.


If you are in prison you will get health care. Or if you are poor and have a baby (for a limited time). Or if you are old. Or if you are disabled and you can prove it to the satisfaction of the SSA. They are the worthy. But being poor or having a preexisting condition does not put you in the worthy category.



That said, I do not support health insurance for illegal immigrants. No country to my knowledge does. But I still believe that hospitals have to treat everyone in an emergency to the point of stabilization. It is not practical to prove citizenship in those circumstances and pretty brutal too.
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Old 09-16-2009, 11:59 AM   #131
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But I don't WANT a health plan that pays for every little thing. If I have one of those, I have to get every little thing approved by the insurance company and I have to fight about every bill for every service. I never know the true cost of anything and I cannot make any reasonable value choices about medical care.

OTOH, I do want to be covered in case there is an accident or very expensive disease in my future. But I can ONLY get that by taking health insurance that includes all that other stuff (and hassle) that I don't want. If I'm unlucky enough to have a pre-existing condition that might affect that coverage, I won't even be able to get that, which means I won't be able to get coverage for future accidents or very expensive diseases at any price, because the coverage I didn't even want cannot be obtained. This is just too twisted.
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Old 09-16-2009, 12:06 PM   #132
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That's the beauty of a free market - it could be whatever some creative group offers that people decide they want to pay for.

Private versus shared room was just an example, I don't know what the cost delta is. I'm sure there are many others I have not thought of, but that's my point, free markets fill needs/wants, sometimes ones we don't even realize we have until they are offered. Another might be more flexibility of non-time-critical procedures:

A) Mr X, you since you paid extra for the Executive Level Plan, you can schedule your wisdom tooth extraction at any of these offices, at any time that is convenient for you.

B) Mr Y, you are on the basic govt subsidized plan. We will call you 24 hours in advance when we have an opening for your wisdom tooth extraction, be prepared to show up at the appointed time and place.

Or maybe two equally effective procedures exist, but one is more expensive, but can be done in a single visit, the other requires multiple visits. The Executive might choose (and have access to, since he paid extra) the more expensive procedure, because his time is money to him. And on and on.

And if no one wants to pay extra, there is no extra plan - it's a free market, with a govt admin plan as a back-stop. It just opens up options that maybe the govt "one size fits all" might not include.

I guess I don't see how these options add any burden to people who accept the basic voucher (if that is what you are saying).

-ERD50
I started getting away from my concern that I raised a number of posts back when I provided a link discussing problems with the private health insurance market. As I said above, and Rita discussed a bit as well, if you make the public option too much less desirable than group options the risk is that the public option market will be unstable and become expensive from adverse selection, especially if it is required to be a self supporting program.

And maybe it won't be a problem, maybe there will be enough people in the market to make it work. It just is an issue that will have to be followed if current proposals get passed. With employer coverage the best deal the private market and if it exists, the public option market, may end up being second class coverage. I don't care if group benefits get you a few tasty morsels, but I don't want to see the public option ending up like the crappy plans that are allowed in many states.
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Old 09-16-2009, 12:09 PM   #133
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But I don't WANT a health plan that pays for every little thing. If I have one of those, I have to get every little thing approved by the insurance company and I have to fight about every bill for every service. I never know the true cost of anything and I cannot make any reasonable value choices about medical care.

OTOH, I do want to be covered in case there is an accident or very expensive disease in my future. But I can ONLY get that by taking health insurance that includes all that other stuff (and hassle) that I don't want. If I'm unlucky enough to have a pre-existing condition that might affect that coverage, I won't even be able to get that, which menas I won't be able to get coverage for future accidents or very expensive diseases at any price, because the coverage I didn't even want cannot be obtained. This is just too twisted.
Yup.
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Old 09-16-2009, 12:19 PM   #134
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I will be as nice as i can be. good health "insurance" is not a right it is part of a pay package you get for working (part of your pay). so its something we work hard for. i would expect the guy who gets up in the morning drives 50+ miles to WORK to get better care then the guy sitting home watching TV Not Working. i hope this doesn't get zapped
poplew, even though I am big on the whole "personal responsibility" thing, I agree with Martha that there are issues with having HC tied to employment (can be tough to change jobs, start your own business, and even responsible people lose their jobs sometimes).

And I don't like the idea that someone who falls through the cracks cannot get efficient medical care (although I've heard that a poor person w/o ins will get care, but they won't get much in the way of preventative treatment?). I think that caring for people is not only the "right" thing for our country to do, but probably also the most cost effective overall (avoid the ER treatment of small issues, and get preventive care).

Here's a thought that has been running through my mind though.... I think most people want any govt subsidy to be a "helping hand up and out" of a problem for most people (some will need a lifetime of support though). So what if you had to take a govt hand-out for ins for 3 years, but then got yourself into a good employment situation? Why not track what people have received in bennies, and then deduct them at some reasonable % over their life so that they are paid back? Similar to student loans. So it's not a "free-bie" for most, but a helping hand in time of need. And why shouldn't they pay it back, once they are settled in? That might make it more acceptable to a larger population?

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Old 09-16-2009, 12:22 PM   #135
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that is what people are concerned with the proposals.... that rationing will kick in big time...
Yeah. Unfortunately we do know that we need some rationing. McAllen Texas does too many procedures as compared to Rochester Minnesota or El Paso Texas. McAllen needs some "rationing" out of unnecessary care. I think that we have to look at positive creative ways around the incentive problem of pay per service.
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Old 09-16-2009, 12:26 PM   #136
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So what if you had to take a govt hand-out for ins for 3 years, but then got yourself into a good employment situation? Why not track what people have received in bennies, and then deduct them at some reasonable % over their life so that they are paid back?
In principle I like this, but in practice I don't know that it's a good idea to create a financial disincentive for getting back on your feet.
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Old 09-16-2009, 12:45 PM   #137
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As a country, we can make something a right if we want to.

If you have money no one says that health care should be free.

I know someone who was laid off in his mid 50s, he can't get health insurance as he couldn't afford COBRA and now can't get on the state's risk pool because he didn't take COBRA. He is looking for work and hasn't found it. So no chemo for him if he gets cancer?

Our country currently divides people into the worthy and unworthy for health care, in my mind in an arbitrary fashion. Some people have the right and some do not. In most states if you are poor but not elderly, not totally disabled, or don't have young children there is no health care program for you. You are not worthy. This is also true if you are working for an employer that doesn't offer health insurance and you can't buy or afford to buy on the market, or if you are laid off and can't find work and can't pay the premiums, or if you are homeless and have no skills to get yourself into the work force, or if you are partly disabled and just can't find work, or yes, even if you are just a lazy ass sitting on the couch. But given that there is no "dole" the number of lazy asses sitting on the couch fully able to work but not doing so because they just don't want to may not be too high, though I suppose they could be sucking off of a spouse or family.


If you are in prison you will get health care. Or if you are poor and have a baby (for a limited time). Or if you are old. Or if you are disabled and you can prove it to the satisfaction of the SSA. They are the worthy. But being poor or having a preexisting condition does not put you in the worthy category.



That said, I do not support health insurance for illegal immigrants. No country to my knowledge does. But I still believe that hospitals have to treat everyone in an emergency to the point of stabilization. It is not practical to prove citizenship in those circumstances and pretty brutal too.
I have some questions;

1, did he save for emergence's?
2. does he have a car payment?
3. dose he have a home or other assets?
4. has he been on vacation in the last 10 years?
Personal responsability



Emergent care is offered to people you will just need to pay the bill.
No free rides
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Old 09-16-2009, 01:32 PM   #138
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In principle I like this, but in practice I don't know that it's a good idea to create a financial disincentive for getting back on your feet.

Big burden on the poor that will continue to help keep them poor. We already have a big spread between haves and have nots. You are on public assistance when your kids are babies, are forced off into a shitty job and get a bill to start paying it back. I don't know the current state of the law but I do know that it used to be that when kids went into foster care their parents would be billed for the care. It was a huge burden on the family.


I am ok of having things like medicaid liens on your assets to if you die medicaid gets repaid first.
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Old 09-16-2009, 01:54 PM   #139
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I have some questions;

1, did he save for emergence's?
2. does he have a car payment?
3. dose he have a home or other assets?
4. has he been on vacation in the last 10 years?
Personal responsability



Emergent care is offered to people you will just need to pay the bill.
No free rides
Wtf does going on a vacation have to do with this? If you are poor you don't get vacations? He lives in California. Doesn't own a home. Gets laid off frequently because of the nature of his work. Divorced. No savings to speak of--rent is high and income is low. He even has roommates to share expenses. Has health problems so he can't buy insurance on the individual market. Owns an older vehicle free and clear, as a car is necessary to find and keep a job in LA.

Come on, do you know people who have unskilled jobs and who make $20,000, $25,000 a year? I know many in that position. They work hard, rent, have cars that have problems or payments. There isn't room to save for months and months of unemployment.

I also know people who have jobs that offer no insurance and due to preexisting conditions they can't buy any. Minnesota has Minnesota Care, which subsidizes health insurance for the working poor, with the poor paying a sliding fee. Is that so bad? Minnesota has one of the lowest percentages of uninsured in the US (after MA with its reforms).

The polarization on this issue in the country is tough. You and I are so far apart on our world views that there likely will be no way that we will ever be able to discuss the issues without being just irritated with each other. I feel so strongly about people being accused of irresponsibility when bad things happen to them that it is hard for me to even type this and maintain a modicum of politeness.
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Old 09-16-2009, 02:36 PM   #140
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Yeah. Unfortunately we do know that we need some rationing. McAllen Texas does too many procedures as compared to Rochester Minnesota or El Paso Texas. McAllen needs some "rationing" out of unnecessary care. I think that we have to look at positive creative ways around the incentive problem of pay per service.

I don't disagree at all... I saw the same program about McAllen... I think they do a lot since it is one of the poorest counties in the nation... so a lot are on Medicaid... and why not charge the government more procedures... you don't want to be discriminatory against the Hispanics do you (yes, this is a bit of a rant... probably will be edited)...


The real problem is where is the line between rationing out the unneeded medical procedures and the needed ones...
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