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Old 12-10-2017, 11:55 AM   #21
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The Mods seem awfully touchy, but I will ask a question hoping it hasn't crossed the invisible line:

Is there really a case where someone is absolutely refused lifesaving care due to no insurance? I have always been under the impression that part of the reason our HC insurance and medical costs are so high is that they have to cover the uninsured through the insured and paying?

I have an employee ($15/hour laborer) who has a granddaughter born with congenital heart defect. The granddaughter was born to a single mom, with no job/income. The child still went through multiple life saving surgeries and I am happy to say is alive and recovering. I am pretty sure there will be bankruptcy, and a tough road ahead, but care was provided in this case. I assumed this is the norm (although a part of the reason for spiraling costs)?
Are people refused? Probably a small minority. Do people who have assets chose to die without treatment? Yes!

My FIL was diagnosed with a treatable cancer, kept it a secret and died from it. He was also a bi-polar person and when depression hit him it was severe. He never told the family what he was doing. He told his neighbor who mentioned it after the event. It did make sense in that a normally active person started hurting too badly to go for his normal walk. We watched him go down hill for two years.

It's hard to understand how a sick person's mind works. He had assets and Medicare, he just didn't believe they would pay his bills.
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Old 12-10-2017, 11:59 AM   #22
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I don't think the issue is "lifesaving care" so much as it is long-term care for those with dementia, etc.

Also, I'd be willing to bet that the HC system, being made up of people, is far more interested in preserving a child's life than in keeping a demented old person comfortable for years and years.

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Is there really a case where someone is absolutely refused lifesaving care due to no insurance? ?
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Old 12-10-2017, 12:03 PM   #23
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If a person has Medicare and all the supplements available to purchase, would there be an out of pocket maximum for even the most serious illness?
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Old 12-10-2017, 12:15 PM   #24
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I have written about this beforehand, my old megacorp, like other megacorps, have a bulk of their employees go to certain hospitals in a certain geographical area. My megacorp would pay, say 10 hospitals, $1 million a piece, guaranteeing them a certain amount of patients and assuring them that they could "keep the lights on". This stipend would allow for so many births, this many heart attacks, that many broken bones etc. We, the employee, in turn, got a better rate for whatever procedure, that the "insurance" would cover. I never paid a co-pay, but I paid $10 for an office visit. I paid about $125 every two weeks for my premium, for a family of 4.

However, since I retired, they dropped me like a hot potato and threw me to the perils of the open market. Which DW and I have somewhat planned for, including the loss of SS and our pensions.
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Old 12-10-2017, 12:21 PM   #25
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Well we have, and don't see any reason in the future we won't continue to have, health insurance. So I cannot imagine an issue that would sink us.

That said I have to wonder if I'd being willing to spend personally (on myself) beyond a $1 million in the event of a specific medical crisis. Sitting here today, I cannot imagine that that $ amount and my desired future ongoing physical quality of life are compatible.

But this is one of those situations you hope to the Gods you never get tested on...
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Old 12-10-2017, 12:25 PM   #26
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So if I ran a health insurance company, I'd buy some hospitals (different company registration) and have my hospitals charge the health ins company a high rate to ensure the 80% is met, then pay out dividends to the company owner (which is the health ins company).
I'd probably add some pharmacies/drug companies in the mix to make sure all my customers spent the full amount as many each year would not go to hospitals.

A nice vertically integrated system of companies would assure removal of pesky refunds.
Great idea! Problem is that the regulatory and commercial capital requirements for an insurer owning a hospital would high so that is unlikely to happen.

The inverse may work though..... you may have seen in the news last week that CVS is buying Aetna.... but between competiton and regulatory constraints gouging is unlikely to happen but CVS may well be able to capture a bigger slice of the pie.
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Old 12-10-2017, 03:21 PM   #27
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Does anyone know how small, medium, large companies fare in the HI pool. Obviously, large companies, 6000 employees or more get the best rate for their employees. Or is it based on how healthy those employees are? I recall our mega corp HI had a $1 M cap on what they'd pay out. Our yearly choice of plans offered low deductible to high deductible plans based on monthly premiums and HSA's etc, but we never paid attention to that $1 M cap because it seemed out of the question that would ever happen. The ACA did away with that cap, right?

And one more thing, other countries who offer single payor negotiate the cost of services, tests, ex rays, prescription drugs. Our insurance companies also negotiate the cost of services with the hospital. My hospital charged around $1141 for a CT scan. The insurance adjusted that cost down to $138.06 based on explanation of benefits. So, a person without insurance gets a CT scan and the full amount, $1141 is either written off or charged to tax payers. The amount charged to my deductible is $138.06. Where does the hospital get the figure $1141? Someone told me if I went to a hospital 50 miles away, they might charge $500 for a CT scan. But if that hospital is out of network, I pay the whole $500. This does not make sense. And if you go to the ER, your insurance covers everything, except co insurance. So you go to the expensive ER and get covered. Craziness!
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Old 12-10-2017, 03:24 PM   #28
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Can't afford necessary health care?

Go out and commit a serious felony. Don't try to cover your tracks, leave plenty of incriminating evidence. Get tossed into prison. You know get free health care.
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Old 12-10-2017, 03:36 PM   #29
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Does anyone know how small, medium, large companies fare in the HI pool. ...
There is really no HI pool. Most medium and large companies self-insure... they hire an insurer to help them design a program and to administer their claims for a fee and they sometimes buy stop-loss coverage in case they have a particularly bad year.
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Old 12-10-2017, 03:41 PM   #30
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-4th child born with rare disease and family racing all over the country for specialists to cure child. The child passes away at 5 yrs. old.
Sad to say it, but there will always be situations that are beyond fixing. Some diseases can't be cured, and some diseases may be curable but at a cost that makes it unreasonable to do so. People will always die.

I think the best we can hope for is healthcare system that provides relief for the most common, addressable health issues at a cost that doesn't bankrupt us.
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Old 12-10-2017, 04:00 PM   #31
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Can't afford necessary health care?

Go out and commit a serious felony. Don't try to cover your tracks, leave plenty of incriminating evidence. Get tossed into prison. You know get free health care.
Better yet, give all your income producing assets to me, and you will be low-income. Same result and no prison.

You can have all the assets you want, you just need to be low-income and it's free.
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Old 12-10-2017, 04:05 PM   #32
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I think you are wrong. Here's why.

Since ACA, health insurers must spend at least 80% of premiums on claims in any given policy year. As a result, the maximum that they have available for taxes, overhead and profit after paying for claims is 20% of premiums. If they do not spend at least 80% on claims then they need to refund any excess premiums until the claim ratio is 80%.

So if they collect $100 in premiums and only spend $75 on claims then they would need to refund $6.25 in premiums to policyholders.

The recent escalation of health insurance premiums is not greed on the part of the health insurers since their margins are limited by law.... but rather is the escalating cost of health care (docs, hosptals, meds, etc).

The 80% was typical even before the law required it... we know this because in the year that the MLR requirements went into effect there were some minor refunds but not a lot in the whole scheme of things.
That's the Medical Loss Ratio for insurers.

But there is no MLR for pharmaceuticals, hospitals, doctors, medical device makers, etc.

Cost is the biggest problem in the US health care system and that comes down to prices charged. We've seen the articles about how the same procedure, such as MRI scans or hip replacement, is charged by different providers across the country.

And also the difference in prices for those procedures between those who are insured and uninsured.

And how those prices, regardless of where in the country or whether insurance rates are in effect or not are higher than those in other countries.

There is no attempt to address prices or "bend the cost curve" because it just may not be possible to tell doctors, pharmaceuticals, hospitals, etc. that they must take less money than they've been getting all these years.
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Old 12-10-2017, 04:05 PM   #33
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...The recent escalation of health insurance premiums is not greed on the part of the health insurers since their margins are limited by law.... but rather is the escalating cost of health care (docs, hosptals, meds, etc)...
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Yep. The profits insurers are making are transparent and easily monitored. We know what they are.

The costs insurers are paying on our behalf are not so transparent. And insurance customers are part of the problem screaming bloody murder when their choice of providers (based on cost to the insurance companies) is limited by networks, etc. We all want to go where we want to go with cost as a secondary consideration and have insurance pick up the bill. Then we gasp when we find out what was paid and when premiums go up...
The word for this is "moral hazard". If I were really sick, and there's a $1-million dollar treatment that would give me a mere 1% chance of living another 5 years, I would say "go for it", but only if I do not have to pay.

When someone else is paying, the sky is the limit.
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Old 12-10-2017, 04:15 PM   #34
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The Healthcare crisis in the United States will only be solved with some type of socialized healthcare system.

The millennial generation demographic does have the ability to make it happen.
We almost just witnessed it.

As the WW2 generation and the older baby boomers die off the The United States will see real change from younger generations to create socialized healthcare.

It will happen.
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Old 12-10-2017, 04:17 PM   #35
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That's the Medical Loss Ratio for insurers.

But there is no MLR for pharmaceuticals, hospitals, doctors, medical device makers, etc.

Cost is the biggest problem in the US health care system and that comes down to prices charged. We've seen the articles about how the same procedure, such as MRI scans or hip replacement, is charged by different providers across the country.

And also the difference in prices for those procedures between those who are insured and uninsured.

And how those prices, regardless of where in the country or whether insurance rates are in effect or not are higher than those in other countries.

There is no attempt to address prices or "bend the cost curve" because it just may not be possible to tell doctors, pharmaceuticals, hospitals, etc. that they must take less money than they've been getting all these years.
I totally agree with all of what you wrote. I was responding to a previous post that opined that the problem with health insurance costs started when health insurers became for-profit companies.

If I were king, any health services provider would be prohibited from charging for any service more than twice the lowest cost negotiated rate charged to heath insurers (excluding Medicare/Medicaid prices since they are imposed by the provider)... that would tighten up pricing but still provide some leeway to differentiate.
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Old 12-10-2017, 04:19 PM   #36
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The Healthcare crisis in the United States will only be solved with some type of socialized healthcare system.

The millennial generation demographic does have the ability to make it happen.
We almost just witnessed it.

As the WW2 generation and the older baby boomers die off the The United States will see real change from younger generations to create socialized healthcare.

It will happen.
I hope you are right - for the sake of our grand children. I don't see it happens in my life time :-(
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Old 12-10-2017, 04:35 PM   #37
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Is there really a case where someone is absolutely refused lifesaving care due to no insurance? I have always been under the impression that part of the reason our HC insurance and medical costs are so high is that they have to cover the uninsured through the insured and paying?
I think it depends on the nature of the illness. In the case you posted about the need was clear and immediate so of course the surgeries were done. But what if the need for care is spread over a longer time and is less immediate?

I have undergone surgery twice this year for melanoma. Fortunately I have excellent health insurance that picks up where Medicare leaves off and I usually don't even get a medical bill at all. BTW, in both cases the melanoma was caught very early so no issues with that.

But the second instance was found during a follow-up visit after the surgery for the first and the surgeon acknowledged that he wouldn't have biopsied it if he hadn't known about the history because it looked so benign. That one also turned out to be malignant and I got the needed care before it got any worse.

It occurs to me though, that had I not have the HI that I do, would I have had the same results? I kind of doubt it. The first instance was just a funny-looking dark spot on my arm but it certainly didn't scream "melanoma". Even the dermatologist that I went to didn't seem concerned and said it was probably a keratosis, which is not harmful.

So had I waited because I had no HI, by the time the melanoma had progressed to the point that I clearly would be needing medical care it may well have been that the care most appropriate would be hospice. I think it fair to say that I will (probably) live much longer simply because I have good HI.

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Can't afford necessary health care?

Go out and commit a serious felony. Don't try to cover your tracks, leave plenty of incriminating evidence. Get tossed into prison. You know get free health care.
I know this is supposed to be facetious but I knew a guy who did exactly that. Destruction of County property is a felony in MD. He needed kidney dialysis on a regular basis and would periodically throw a large rock through the glass door on the police station, be arrested, go to jail, and then get his dialysis on the County's dime.

In the winter this caused the desk clerks to freeze because it took several days to get a new door, and the door was very expensive, so we asked him to throw his rock through one of the smaller windows that would cause less heat loss and were a lot cheaper to replace. Unfortunately we didn't specify which window, so the next time he obliged and threw the rock through the station commander's office window. To say he was unhappy about it is a gross understatement.
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Old 12-10-2017, 04:38 PM   #38
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Well we have, and don't see any reason in the future we won't continue to have, health insurance. So I cannot imagine an issue that would sink us.

That said I have to wonder if I'd being willing to spend personally (on myself) beyond a $1 million in the event of a specific medical crisis. Sitting here today, I cannot imagine that that $ amount and my desired future ongoing physical quality of life are compatible.

But this is one of those situations you hope to the Gods you never get tested on...
They are rare, but I recall reading of one family where the ins. dropped them after spending millions, as the insurance company claimed they exceeded there $5 MM limit !!

Even ins. companies know you can spend more than $5 MM on a health issue, which is why this seems to be a common limitation.

County employee files $5 million health insurance claim
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Old 12-10-2017, 04:48 PM   #39
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....Is there really a case where someone is absolutely refused lifesaving care due to no insurance? I have always been under the impression that part of the reason our HC insurance and medical costs are so high is that they have to cover the uninsured through the insured and paying? ....
I'm no expert but the impression that I have is that if you have an injury that is life threatening that you will be treated whether or not you have insurance... however, if you have an illness like cancer that is life threatening and don't have insurance that you are up a crick without a paddle and would have to rely on charity care.
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Old 12-10-2017, 04:52 PM   #40
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They are rare, but I recall reading of one family where the ins. dropped them after spending millions, as the insurance company claimed they exceeded there $5 MM limit !!

Even ins. companies know you can spend more than $5 MM on a health issue, which is why this seems to be a common limitation.

County employee files $5 million health insurance claim


Not saying it can’t happen: just for me out of pocket north of $1 million... I don’t know.

In any case, at least for now with ACA being law of the land HI can no longer have a lifetime cap (at least that is my memory of law).
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