Insurance Industry For Universal Health Care

Steve Benen has a good post on it and what it means. As I have said repeatedly, not knowing a damn thing about health care policy, I leave commenting on this to those who do.

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    Well, the question of a mandate (5.00 / 5) (#1)
    by inclusiveheart on Thu Nov 20, 2008 at 09:00:09 AM EST
    is secondary to the question of what people will get for their money.

    The real crisis in the healthcare arena is non-payment by the health insurance companies when people get sick.  So this isn't just about getting everyone in America a little healthcare card, it is about that card delivering a return on investment.

    Until there is a government plan option that is affordable, there will be no competition for the health insurance companies to incentivize them to keep their premiums low or deliver on their promises of coverage when a customer gets sick.  

    As a short-term fix, it would also help if the new AG would look into price fixing in the industry, but that cannot be viewed as a long-term solution because the next Administration that comes in that doesn't care to enforce the laws will just allow them to do it again.  The only way to keep them in check is to offer a competitive government plan.  I'd envision this plan being an extension of Medicare to all.  It would be up to the insurance companies to figure out ways of competing with that or selling plans to supplement the coverage.

    Re: (5.00 / 2) (#6)
    by vicndabx on Thu Nov 20, 2008 at 09:09:41 AM EST
    competetive Medicare plan

    You do know who processes and pays the claims under both Medicare and Medicaid - private insurers under government contract.  

    The important aspect of the Medicare (5.00 / 5) (#13)
    by inclusiveheart on Thu Nov 20, 2008 at 10:04:22 AM EST
    plan is that the procedures, care, surgeries etc. that are covered are covered.  There is generally little debate about or delay of care as compared to what people face when they are privately insured.  Medicare is not perfect and certainly government is not likely to cover absolutely everything ever - especially in this backwards country - but the basics of coverage are there.

    The private insurance companies are for profit entities and as such are looking to maximize profit.  That means that rather than covering costs their real mandate is to find as many ways as possible to avoid covering costs when people call in their policies.  That is completely dysfunctional and at cross-purposes with the very real need to keep a healthy working population in this country.  

    The only honest broker of health insurance in this country right now is the government.  The only way to force the health insurance industry to become an honest broker is to set them up against competition that offers a "gold standard" at an affordable price point.  Regulating them will not work and if we tried we'd be wasting time and money litigating when we could just deliver healthcare to people directly.

    The economic benefit to companies, individual citizens and our economy as a whole is huge here too.  Kennedy has set up those work groups and sadly the one that is missing that would arguably drown out the Healthcare Lobby is the one that would and should focus on the positive impact of a national health system across all constituencies - except maybe the existing health insurance providers.  

    The first order of business should be establishing the standard of care - then we should be talking about the mandate and pricing.  If we accept the standard as it has been over the past many years, then we haven't done anything but further enrich the health insurance industry because everyone understands that the lowest cost per person for basic insurance can only be achieved with the highest number of people contributing to the pool - mandates are going to happen - that's a given.


    Out of synch w/reality here (none / 0) (#22)
    by vicndabx on Thu Nov 20, 2008 at 10:50:40 AM EST
    That means that rather than covering costs their real mandate is to find as many ways as possible to avoid covering costs when people call in their policies.

    Don't know what insurance companies you've worked at, but the one I work at doesn't do this at all.  In fact, most claim processing is automated.  Claims come in, most process and pay the same day.  Payments go out on a regularly scheduled basis.  Now, of course certain procedures are investigated further based on a number of variables (necessity, contract rules, etc.) but this is not the majority.

    Here's my problem, the starting point w/our side is too often, there's the bad guy let's go get them and make em pay!  That's the wrong attitude to have if you want a constructive discussion.

    You also say

    The private insurance companies are for profit entities and as such are looking to maximize profit.

    Of course this is true, but profits are not maximized by denying claims.  Profits are maximized by increasing sales and reducing overhead.  How much money do you think an insurer actually saves by denying claims?  Do you realize how many claims would have to be denied to offset what get's paid?  Think about it for a minute.

    Lastly, you said

    The only honest broker of health insurance in this country right now is the government.

    As is explained w/in this thread - health insurance (at least in my state) is highly regulated, and $$ paid to providers or care is often negotiated.  What folks often fail to realize is private insurers tailor their coverage very closely to what CMS (the gov't entity that oversees Medicare/Medicaid) covers from a level of care perspective.  Level of care ain't the issue.  It's affordability of coverage for the level of care.  That only comes w/more people in the system.


    I'd be willing to bet... (5.00 / 2) (#24)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 10:55:44 AM EST
    ...that your Company does in fact look for ways to not pay/delay payment/avoid payment of penalty and interest on their claims.  I have yet, in all my years, not found one who doesn't.  "Auto" adjudincated or not.  

    Indeed, you are right (none / 0) (#25)
    by vicndabx on Thu Nov 20, 2008 at 11:14:56 AM EST
    hence my "regularly scheduled."  However, this does not translate to avoid/deny paying for services rendered to a subscriber with active coverage whose claim is valid.

    HAving worked for and written software (5.00 / 3) (#27)
    by smott on Thu Nov 20, 2008 at 11:31:31 AM EST
    for INs Cos that in fact perform the auto-adjudication...

    Only the simplest claims get AA'd.

    All else pend for manual adjudication.


    Yes, only the simplest get auto adjudicated, (none / 0) (#45)
    by vicndabx on Thu Nov 20, 2008 at 01:45:22 PM EST
    i.e. AA, but if you were familiar w/the actual claims that come in, you would know this is the vast majority of claims.  Many insurers have something called a "first-pass rate."  Any insurer worth it's salt strives to keep this as high as possible.  Manual work on claims is a time consuming tedious process that is to be avoided - at least from a health insurer's perspective.

    Hmm (5.00 / 3) (#32)
    by blueaura on Thu Nov 20, 2008 at 11:49:37 AM EST
    Having worked in the health care industry for over 5 years* I am skeptical of your claims. From my experience, insurers would use any technicality they can think of to avoid paying claims, or to under-pay them. If your company really does pay most claims the same day, that is very surprising to me. It is generally not in the best interest of a company to pay a bill the day they receive it. (Read up on cash cycles if you don't know why.) Actually, I see that you say "process and pay" the same day, and then say payments go out on a regularly scheduled basis. . . so I imagine that it gets marked "paid" in the system in the same day, but checks or EFTs are probably delayed as long as they can.

    How much money do you think an insurer actually saves by denying claims?  Do you realize how many claims would have to be denied to offset what get's paid?  Think about it for a minute.

    Well it's really pretty basic accounting. Every dollar they deny reduces their expenses. A reduction in expenses goes down directly** to the bottom line, i.e. an increase in profits. So yes they absolutely do profit from denying claims. No one contends that denied claims outweigh paid claims, but they can be significant.

    * I am no longer employed in the industry.
    ** Not exactly, as tax comes in to play.


    I've been in health insurance over 10 years (none / 0) (#44)
    by vicndabx on Thu Nov 20, 2008 at 01:42:47 PM EST
    I have worked with both private insurers as well as companies contractors who handle Medicare claims and can only speak to my own experience.  So no, payments are not "delayed as long as they can" but sent out multiple times per week based on a schedule negotiated with the provider of service when contracted.  

    I also know thru various acquaintances of the processing habits at other insurers, but these are not health insurance companies.  Plans that administer workmen's comp or other liability insurance may have a different mindset.  Be careful not to group all insurers together.  Healthcare is a very different animal.


    Been there, myself (none / 0) (#60)
    by MoveThatBus on Thu Nov 20, 2008 at 08:37:38 PM EST
    Every state has its own insurance commissioner and regulations.

    The BC group I worked for made it a joke that they would refuse to pay until the member got tired of demanding they do so; the provider sent the patient to collections, and the patient finally paid the bill.

    This isn't true on standard claims, but it sure was on anything that fell just a little outside of routine and common treatments.

    It is different from state to state and insurer to insurer.


    As I said (none / 0) (#2)
    by Big Tent Democrat on Thu Nov 20, 2008 at 09:03:11 AM EST
    I leave the commenting on this issue to those who know something about it, like inclusive heart.

    Thanks for filling in the blanks in my post.


    Price fixing? (none / 0) (#16)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 10:14:11 AM EST
    Of what?  Payment schedules?  Nope, those are negotiated between the carrier and the provider.  Premium rates?  Nope, those are regulated by the states.  Rates must be actuarial justified and are reviewed by the state Insurance Departments.  

    There are also market forces that play a role in keeping their rates in-line with other carriers.  Perhaps this is what you are refering to?  Some sort of collusion between carriers to fix rates?

    Insurance companies can be very creative when it comes to claims payment or more correctly, non-payment.  However, this too is under review by the states for complaince with the existing law.  Noncompliance in this area is taken very seriously by the states and monetary penalties can be very severe.  

    Enrollment is fairly well regulated by the States as it pertains to small groups/business groups of one and guaranteed issue, but the requirements for individual enrollment remains at the whim of the carrier.  That needs to change, IMO.  Denying people coverage because they have conditions such as acne is just silly.


    There have been accusations of (5.00 / 2) (#18)
    by inclusiveheart on Thu Nov 20, 2008 at 10:33:50 AM EST
    collusion between the health insurance providers that might very well be credible.  And the practice of them all getting together and deciding that they are suddenly going to stop covering one thing or another is a bit suspect.  Not exactly free market at all...  

    Big companies are not even finding themselves in a position to bargain effectively against these insurers because they all agree to do the same things - so imo the influence of "market forces" are generally grossly overstated.

    The individual market is a mess and market forces for them don't factor in at all - they have zero bargaining power.

    In any case, investigations would be a temporary fix.  Every time they are threatened with an investigation they clean up their acts for a while and then go right back to their old ways.  Or they just litigate it to the point where it takes so long to get through the system that no one remembers why it started in the first place.


    By "providers"... (none / 0) (#23)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 10:51:18 AM EST
    ...you are refering to the Companies and not the actual practioners, correct?  I have seen no evidence of this type of collusion.  In fact, there are State mandated coverages that they are all reguired to provide.  

    Large groups do still have quite a bit of bargaining power.  However, the consolidation of the industry does have somewhat of a chilling effect on that.  

    Litigation of fines resulting from Market Conduct/Financial examinations is not common at all.  If they don't fix the problems and they are found, it becomes a willful violation and the penalties are severe.  But believe me, we certainly don't forget.

    However, it is a fine line to be walked.  The States want to encourage competition and consumer protection, but not put Companies (especially those serving rural/under served areas) out of business.  


    Yes I was refering to the insurers (5.00 / 3) (#30)
    by inclusiveheart on Thu Nov 20, 2008 at 11:46:00 AM EST
    not the physicians, hospitals etc. when I said health insurance providers.  

    There was an issue probably now 4-5 years ago where some questions arose around how the leading insurers decided on a policy change that came very close to being to a price fixing issue between the insurers.  I have to try to remember the detail so I can look up the coverage from the time.  They backed off as I recall, but ultimately got whatever concession they wanted after the storm died down.

    In any case, I am advocating for a not-for-profit government run alternative because I've had it with the private insurers.  I don't want to waste time with them anymore.  Their need for profit is in direct opposition to the objective of making healthcare available when and if people need it.  It is one of the dumbest and most wasteful business models possible and at present it is propped up by a labyrinth of regulation and law that for the most part favors the companies' ability to make profits over delivery of services to the customers they are selling policies to.  So, I'm done with them.  We've wasted decades now trying to "strike the balance" and the reality is that if your objective is to create access to care to as many people as possible, the insurance companies have made it all too clear over the years that that is not a profitable model - they answered the question a long time ago as to whether or not the present system is viable - it is not viable and it is not profitable - so I think they ought to be thinking about selling other products because health insurance is just one of those things that can't be done for profit if it is done right.


    No argument here. (5.00 / 1) (#36)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 12:07:33 PM EST
    The model is broken.  As it stands, it is profible for the Companies, but not the consumer.  Not to mention the foolishness of not providing preventative services which in the long-term save more money than not covering them up-front.  Which is cheaper--a colonoscopy or a colon resection and associated cancer treatment?

    I do think there is a place for the Companies in the single payer model.  Either as a TPA for things like administration or as a supplemental provider of additional coverage for those who desire/can afford it.  


    Aren't the administrative costs for (5.00 / 1) (#57)
    by sallywally on Thu Nov 20, 2008 at 08:08:42 PM EST
    the insurance companies quite a bit higher than for Medicare (i.e., not Medicare Advantage, which is administered by private insurance companies)?

    Like maybe 15% vs 4 or 5% for Medicare?


    ummm... (none / 0) (#26)
    by sj on Thu Nov 20, 2008 at 11:23:36 AM EST
    Denying people coverage because they have conditions such as acne is just silly.

    Denying people coverage because they have ANY condition is the problem.  

    Thank you for the information on the way the insurance industry currently [is supposed] to work, but in the end I don't really care about that.  I only care that I am paying hundreds of dollars a month for individual "coverage" and that I get much less for my money than I did when I paid $60-$75 a month for family coverage in the late 70s early 80s before the costs started to visibly skyrocket.  (For the record:  coverage of "self" only was provided by my employer at that time, at no cost to me)

    I don't care a whit who is [supposed to be] regulating the insurance industry.  In the end, the problem is the very fact that it is an industry, and the shareholders must be protected, don't you know.  The policy holders not so much.


    You would care... (none / 0) (#28)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 11:36:55 AM EST
    ...if the States didn't regulate the industry.  It is their committment to consumer protection that keeps policyholders from really getting screwed over.  

    Is it perfect?  No.  The controls and oversight are subject to the whims of the legislatures.  I could write a whole laundry list of regs to improve the oversight and close the loopholes.  But that is out above my pay grade.    

    Is it better than no regulation at all?  You bet.  Just look at the banking/mortgage industry and what the lack of oversight led to.


    Under today's circumstances I really don't care (5.00 / 3) (#34)
    by sj on Thu Nov 20, 2008 at 11:53:11 AM EST
    Could the insurance companies gouge me even more than they already do without State regulation?  Undoubtedly.  But that's not my point.  

    I don't care because regulations or no, the freaking system isn't working.  I have absolutely no vested interest in maintaining any segment of the current structure.  Of course lessons should be learned from it, but I don't really care to learn how it currently is supposed to work.  Maybe all the norms are being followed but the end product -- payment for health care delivery -- is broken.

    I am unmoved by arguments that current regulations and standards are being followed.  I don't trust -- indeed I have disdain for -- the entire current structure.

    Keeping in mind that I do not include the actual medical services themselves when I talk about structure.  Doctors are as scr*wed as patients under the current system.


    Most states (5.00 / 3) (#37)
    by OldCity on Thu Nov 20, 2008 at 12:30:24 PM EST
    regulate health insurers very poorly.  

    A comparison between medicare, workers' comp and group health fee schedules in almost any state will reveal gross inequities.  Further, administering group claims has increased the average physician overhead 60% in the past ten years.  (In Phila, pediatricians were reimbursed 75% of the cost of polio vaccine, exclusive of labor).  

    Factor in float on claims, etc and you see not only poor service by providers, but shrinking access to providers.  Worse, collusion laws are enforced against doctors but not insurers.  


    Payment Schedules are between (none / 0) (#63)
    by MoveThatBus on Thu Nov 20, 2008 at 08:46:40 PM EST
    Insurance provider and employer plan. Every employer designs their own insurance plan for their employees.

    Every company that provides Blue Cross to their employees does not provide the same coverage, but every type of procedure performed by the provider is paid out at the same rate no matter who the patient works for.  

    It's why some doctors refuse to accept certain insurance plans.  The directory of Preferred Providers is the same for all insureds by a particular Insurance Company.


    Correction (none / 0) (#65)
    by MoveThatBus on Thu Nov 20, 2008 at 08:55:01 PM EST
    Sorry - Payment Schedules are between provider and insurance company, but they are not as negotiable as what the insurance plan will cover is between insurance company and employer groups.

    Ezra Klein (5.00 / 3) (#3)
    by Coral on Thu Nov 20, 2008 at 09:03:46 AM EST
    Ezra Klein has a helpful post on this.

    His conclusion:

    Even so, the basic foundation here -- individual mandate, guaranteed issue, some form of community rating -- is the likeliest foundation for a deal, and the political system knows that full well: That's the Baucus plan, the Wyden plan, the Clinton, plan, the Edwards plan, and probably will be the Obama plan. The insurers are recognizing that, and trying to pull the terms in their favor, dangling an easy deal where they endorse passage but have more control over the rate structure (which is to say, there's less community rating). This is the beginning of the fight, not the end of it.

    First thing they need (5.00 / 1) (#5)
    by OldCity on Thu Nov 20, 2008 at 09:05:56 AM EST
    to do is nail down a philosophy.

    Our current healthcare policy has been shaped in part by the "moral hazard" theory.  Essentially, it boils down to an assumption that utilization will increase if coverage is provided.  Utilization will be spurreed by several things, among them more risky behaviors, hypochondria (nuisance treatment), etc.  

    Part of the solution has been to introduce risk sharing.  In most cases, this takes the form of deductibles and co-pays.  The government and insurance companies assumed thiat his would result in more efficient healthcare delivery and reduce wasteful consumption of medical services.

    Obviously, this hasn't worked.  We have more uninsured than ever.  The vast majority of our bankruptcies result from medical expenses.  We are less healthy than other industrialized nations, we lead shorter lives, our infant mortality rate is a disgrace and we perform more late term interventions than other countries.  Why?  Because costs deter people from seeking preventative care, either physician or pharmacological.  Only when the need for care becomes immediate do many seek medical aid, at which point the cost of that aid and the severity of treatment skyrocket.

    So, the opponents of universal healthcare and believers in the free market for healthcare need to first disabuse themselves of the quixotic notion that "moral hazard" will create an economically unfeasibile burden on the American public.

    At present, the sick pay disproportionately  more than those who are well.  We're conditoned to think that the actuarial model practiced by property/casualty companies is fair.  Perhaps it is, but not in terms of healthcare.  In healthcare, risk sharing is by far the better solution, as it ensures that more people will obtain adequate care and will end up being less of a financial drag on other social welfare systems, because they will remain solvent.

    I realize this somewhat oversimplifies the debate, but the inception of program and policy design will require rejecting fundamental assumptions that have been in place for years.  Further, the government is going to have to develop a way to sell this to the public in a way that makes sense to them, and isn't seen as a new tax.  Political will aside, this is high concept stuff and we're all conversant with the abilities of our politicians to reduce high concept to inanity.        

    There are a couple problems with (none / 0) (#8)
    by Slado on Thu Nov 20, 2008 at 09:21:42 AM EST
    your theory.

    Its not simply a mater of preventative care.  Our countries health statistics are scewed by other factors...honest reporting, murder, freedom to do stupid things etc...  

    America is the most free county in the world.   We are free to drink, smoke and eat as much as we want and we choose to do so to great excess.  Other countries smoke too much, drink too much or eat too much but none do all three to the extent that this one does.

    The real issue is do we want a system that provides all the preventative care you want for free but limits extreme care by rationing or a system that lets frees the lower tier care from government mandates giving patients more choices and price control?  We have the most technically advanced critical care helth system in the world.   This is driven by the ability to make money finding new ways to save lives.  The problems are low leve care cost overuns make getting a flu shot more expensive then it needs to be.    It is insane that it takes the same amount of paperwork to have a routine appointment with your doctors as it does to have a brain operation.  It should cost a lot of money to have a dboule bypass.  It should not cost as much as it does to have a CT scan.   The cost over runs are do to government mandates, a system that does not provide real choice at the lower level and little if any price control.

    A universal system will result in a two tier sytem in this country.   The poor will get the government system the rich will get private care.   Unless the government is able to mandate some sort of fairness law like Canada (who has the luxury of having the US next door) we will see a two tier system that is just as unfair as the current one.

    You can't make people take care of themselves and you can't make people be insured, look at car insurance.   All you can do is make entry level healthcare more affordable and frankly a government system would not do that.


    My state (none / 0) (#11)
    by cal1942 on Thu Nov 20, 2008 at 09:26:36 AM EST
    you can't make people be insured, look at car insurance.

    has mandated auto insurance for several decades.


    So has mine... (5.00 / 2) (#12)
    by kdog on Thu Nov 20, 2008 at 09:59:36 AM EST
    But we've got loads of uninsured drivers on the road...they can't afford it so they become uninsured criminal drivers instead of just uninsured drivers.  

    Passing a law saying you have to have insurance doesn't magically make it affordable.  Without the affordability, all you are doing is creating a new set of criminals.


    You know (none / 0) (#43)
    by Fabian on Thu Nov 20, 2008 at 01:30:52 PM EST
    Not sure why there's any issue with them being "criminals".  After all if they are never ever found out they are fine.  Now if they get into an accident and injure someone, they are in trouble anyhow.  The law just means they are in more trouble.

    Rule One:   Don't do it.
    Rule Two:   If you do it, don't get caught.
    Rule Three: If you do get caught, see Rule One.


    My father is a doctor and he made this point to (none / 0) (#49)
    by Slado on Thu Nov 20, 2008 at 02:44:45 PM EST
    me last night when we got into a conversation about univeral insurance/healthcare.

    It will be awfully hard for the government to throw a sick kid into jail or the parents of a sick kid for not having insurance when the kid gets cancer etc...  I can see the story on CNN now.

    So baring it being a criminal activity how is the government going to make sure everyone gets insurance?  

    Look no further then Wal-mart on how little preventative care could cost if it weren't for the goverment requiring insurance and etc...


    A bigger pot (5.00 / 3) (#7)
    by Carolyn in Baltimore on Thu Nov 20, 2008 at 09:21:07 AM EST
    A mandate to them means they can sell to everybody. A mandate to me would mean Medicare for all and the insurance companies can sell add-ons.
    Seems to me the biggest cost in healthcare is the billing and bill-collecting process and the profits. I'm not sure we can be competitive with other countries until we have real universal healthcare like civilized countries do.

    Universal healthcare would save our automakers very quickly BTW. That is the biggest cost and other automakers from countries with health care do not have this as an added cost.

    My first thought (5.00 / 4) (#9)
    by cal1942 on Thu Nov 20, 2008 at 09:21:47 AM EST
    on this was that the health insurance industry is trying to save their own skin. It's pretty obvious that something has to give regarding health insurance and given skyrocketing costs, anecdotal stories of industry perfidy, a Democratic administration and White House, they may believe that they are in a weak position.

    With all that's gone down in the last 15 years Harry and Louise ads would probably fail miserably and they know it.

    Their strategy may be to fight against a competing government plan, a Medicare for all option, that would eventually lead to their demise.

    This development isn't a big surprise, I think they see the writing on the wall.

    I hope Congress and the White House see this ruse and offer a Medicare type option.  The HI industry is in a bad spot and would be fighting a losing battle. They have no cards to play.

    I think Obama may have been coming around (none / 0) (#58)
    by sallywally on Thu Nov 20, 2008 at 08:19:41 PM EST
    to having a government-run program (like Medicare) available to those who want it. I've heard this very recently.

    I remember also Edwards describing something like this in his plan and saying that over time everyone would choose to be part of it and the insurance companies would go by the wayside. He was grinning a lot when he said this.

    I think it's a great idea, and exactly correct. No one will choose health INSURANCE if they can have health CARE.


    the environment, stupid (5.00 / 1) (#10)
    by Carolyn in Baltimore on Thu Nov 20, 2008 at 09:25:57 AM EST
    I just realized and wanted to add that if everyone gets covered, there would be true incentive to make safe workplaces, a safe environment, preventative care, healthy foods. If we are all paying for the cost of a commons that is bankrupt I think there's be more will to make the environment healthier for us all.

    That is kinda what scares me... (none / 0) (#14)
    by kdog on Thu Nov 20, 2008 at 10:05:15 AM EST
    when the state is paying the healthcare for everybody, how long before eating at McDonald's is a crime?

    Like my old man always said..."If I'm paying the bills I'm making the rules".  It probably is farfetched, but if the state can prohibit reefer they can prohibit anything...and it makes me nervous.


    No worries (5.00 / 1) (#29)
    by sj on Thu Nov 20, 2008 at 11:40:06 AM EST
    There are McDonalds in lots of countries that provide UHC including the UK, Canada and Costa Rica.

    Paying premiums to health insurers sure hasn't proven your dad's credo.  We're paying the bills AND must play by their rules.


    Ya got me there sj... (none / 0) (#31)
    by kdog on Thu Nov 20, 2008 at 11:47:12 AM EST
    I guess the eternal cynic in me assumes the worst when it comes to big brother.

    Not just food though...tobacco, alcohol, skydiving, anything fun with a health risk...do you think the state would become more nanny-like under a UHC system?  I fear it is inevitable.  If I could be convinced the state would not become overly nanny-like, I'd be much more willing to get on board.


    I think it's the insurance companies (5.00 / 1) (#59)
    by sallywally on Thu Nov 20, 2008 at 08:29:56 PM EST
    (and the other corporations, of course,) who are actually Big Brother.

    A big, unaccountable, unelected government.

    And they control us AND the state and federal governments (at least the Dems) hook, line and sinker.


    Yes because skydiving (none / 0) (#41)
    by smott on Thu Nov 20, 2008 at 12:57:56 PM EST
    ...is prohibited in all those other countries that provide UHC...

    Just asking.... (none / 0) (#42)
    by kdog on Thu Nov 20, 2008 at 01:10:48 PM EST
    would you bet your life on there being no further restrictions to the freedom we have left under a UHC system?

    I'm a gambling man and I wouldn't.


    I'm more inclined to think (none / 0) (#50)
    by sj on Thu Nov 20, 2008 at 03:10:33 PM EST
    that further restrictions are likely to come from Department of Homeland Security than from UHC.

    LOL... (none / 0) (#40)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 12:55:41 PM EST
    ...I think you've been having a craving for a double cheeseburger for a couple of days now, huh?  

    All this talk of Mickey D's is sure making me want one.


    As an addendum to my earlier post... (5.00 / 1) (#15)
    by OldCity on Thu Nov 20, 2008 at 10:05:52 AM EST
    Mandayes mean very little without structure.  A reply to my post seemed to suggest that I advocated late term raitioning, which is common in most countries with socialized healthcare.

    I don't advocate that at all.  Frankly, I don't think our program will be administered by the government.  However, We are going to have to make hard choices about how we obtain care, how we will structure fees for coverage, how much rsk sharing will be involved on in individual and pool basis, and what our covered service benchmarks will be.

    I am a consultant who;s more than a little conversant.  The poster above seemed to distill a complex issue down to baseless assumptions.  the poster also assumed that data generated by other countries was unreliable; I'm pretty sure they're not depressing their infant mortality rates or inflating their life expectancy rates.  

    Further, costs are high not because of complexity, though specialists are reimbursed at higher rates than internists, pediatricians or other primary care practitioners.  Costs are high because of enforced complex billing procedures, unfair fee schedules and cost shifting, all resulting from arbitrary rate setting by insurers.  Add on the necessity of protectionist medicine mandated by the need for excessive liability avoidance, and you've got a whole bunch of non-core costs.  

    And, I might add, the government mandates all sorts of insurances...auto, workers' compensation, professional liability...I coould go on.

    The current system places an unfair burden oth on providers and on those least able to pay for care.  At the very least, the system needs streamlined processing of claims and to be far more (universally?) inclusive in order to drive down costs for all.  

    The idea that those who work hard are going to somehow be disenfranchised by health reform is ludicrous.   So is the idea that the poor get sicker.  The poor are more in need of urgent "lifesaving" procedures because they fail to receive preventative healthcare, which forestalls those occurrences.  

    Anyone who examines the overhead costs of a medical practice, insurance company reimbursement rates and gross utilization numbers can confirm what I've written.

    As for mandates...before you can have a mandate, you need a structure.  There's an erroneous assumption above that the Credit default swaps have underwriting similarities or risk sharing similarities with health insurance...they are utterly different.  They failed because they were products turned into commodities that were inadequately capitalized; almost every other form of insurance has capital (reserve) requirements by law.  

    Indeed, the rest of the insurance industry needs (none / 0) (#46)
    by vicndabx on Thu Nov 20, 2008 at 01:53:12 PM EST
    to catch up w/health insurance.  

    At the very least, the system needs streamlined processing of claims and to be far more (universally?) inclusive in order to drive down costs for all.

    HIPAA laws required insurers and providers to utilize standards to facilitate claim and payment data electronically.

    Also, not sure if you were referring to me

    There's an erroneous assumption above that the Credit default swaps have underwriting similarities or risk sharing similarities with health insurance...they are utterly different.

    If you were, that was not my meaning.  Indeed they are totally different.  I simply meant that the more people who actually have something to put into the pot, i.e. monthly premium payments, generally means more will have something to eat when the time comes - and we won't have to ration the food as much.


    I wasn't, but (5.00 / 1) (#47)
    by OldCity on Thu Nov 20, 2008 at 02:07:22 PM EST
    I can tell you that there's huge float on claims.  That's not anecdotal.  I do som medical practice consulting and I can tell you that average payment is +62 for the carriers in our area in all specialties.

    Additionally, merely to bill properly requires a 4 doctor office upwards of six staffers.  

    Now, I'm in the P/C industry and also consult on health insurer issues.  I'm not bashing to bash.  The industry takes unfair advantage of healthcare providers by not promptly paying, by arbitrarily changing standards/processes/reimbursement rates.

    "Adjudication" is a joke.  Audit according to ICD-9 code and pay.  You don't need to "adjudicate" unless there is dispute.  Our company processes with an error rate of under one percent.    


    the only way to provide (5.00 / 2) (#33)
    by cpinva on Thu Nov 20, 2008 at 11:52:17 AM EST
    health care for everyone is "single-payer", universal health insurance. call it socialism if you will, but it serves a national security interest; it assures a viable pool of healthy bodies, in the event of a national emergency, requiring the institution of a military draft.

    as well, it is a matter of national security that every child receives proper nutrition and education, for the reason noted above.

    wwII saw a 25% failure rate on pre-induction physicals, most due to poor health care and nutrition, during the formative years. this country can ill afford that loss of manpower.

    a universal health care system, based on the european model, is the way to go. increase tax rates by 1% for individuals, and 3% for corporations, to pay for it. the decrease in premium costs will offset the increase in taxes.

    if so desired, individuals and companies can still opt for a secondary insurance policy, to cover co-insurance costs.

    paul krugman had a couple of columns discussing this, with cost/benefit data to support his position.

    Yup (5.00 / 2) (#35)
    by DancingOpossum on Thu Nov 20, 2008 at 12:05:16 PM EST
    Everything else is just tinkering around the edges. When people talk about other countries' providing less-good care, especially for the poor, or the long waiting lines, my response is, "At least they get SOMETHING." What good is the "best healthcare in the world" if you can't get it?

    I would venture to guess that if we enacted a national healthcare system and started making sure that people who needed care got care earlier in life, that people just did simple things like had yearly check ups - we'd find that our overall healthcare costs would go down.

    That's what they found in Canada. People don't end up in the emergency room for the flu because they can go to the doctor as soon as they have a sniffle.

    A universal system will result in a two tier sytem in this country.   The poor will get the government system the rich will get private care.

    You know, I actually don't have a problem with that because at least the poor would get SOMETHING--see my line above. No, it wouldn't be great but what are they getting now? Even if you're not "poor," access to health care sucks. I make a decent salary, am extremely healthy, and have what's considered excellent health insurance, yet I'm still out hundreds (even thousands) of dollars every year for stupid things like lab tests that my insurance won't cover or dental visits that they only cover part of. I pray I never get a chronic condition or wind up in the hospital, I will probably have to declare bankruptcy. It utterly blows and I'm one of the "lucky" ones. For people with no health insurance and chronic conditions, it's a death trap.  

    Underwriting is (none / 0) (#38)
    by OldCity on Thu Nov 20, 2008 at 12:34:57 PM EST
    going to be the problem.  Group health is very profitable, despite the popular assumption.  

    The companies are not going to propose anything that isn't as profitable as possible.  I don't blame them...but there has to be a trade off.  They must reduce administrative costs and increase fees schedules for primary practitioners.  

    Further, there have to be equivalencies in coverage.  That's going to be a huge obstacle.


    Underwriting of what? n/t (none / 0) (#48)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 02:30:34 PM EST
    They're (none / 0) (#51)
    by OldCity on Thu Nov 20, 2008 at 03:18:12 PM EST
    going to have to figure out cost...that means they have to quantify risk.  That ain't easy, when you're adding an unknown quantity.

    I'm well aware of what Underwriting is... (none / 0) (#52)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 03:39:30 PM EST
    ...having been an Underwriter for many years.  

    I'm trying to figure out who you are refering to since your original (and subsequent) post aren't very clear on that.  

    Are you talking about underwriting individuals under UHC/SPHC or what?


    I honestly (none / 0) (#66)
    by OldCity on Fri Nov 21, 2008 at 08:42:21 AM EST
    can't figure out what sort of structure is best, UHC or SPHC, and how much emphasis will be paid to well care/preventative care.  I assume that if more weighting is given to preventative care, encouraging more utilzation of internists/GP's/pediatricians/GYN, etc, we'll see a decrease in interventional care, etc.  We may also see a decrease in defensive medicine.  

    As more of an operations guy and a consultant, I'm not really conversant in what sort of model would be used to calculate cost per life, nor how UHC vs SPHC would affect that.  I do believe though, that any change will involve huge structural and operational challenges that will take time (and money) to design and implement, as well as a wholesale redesign of revenue model and fee structure.  

    As an underwriter, I'm sure you know that most companies change cultures with glacial speed.  Even when they adopt deliberate approaches, they usually do it poorly, as well.  So, while I'm all for the US Government finally fulfilling this portion of the Social Contract, I'm almost certain that it will not be done well, that we will see unrealistic cost projections (read inadequate)and an inefficient bureaucracy.



    As Dennis Kucinich said, (none / 0) (#61)
    by sallywally on Thu Nov 20, 2008 at 08:39:40 PM EST
    we're already paying for it. We just aren't getting it. The money is going to an insurance/health system that isn't working.

    By the way, it's preVENTive care, not prevenTAtive care. A vaccine is a prevenTAtive or a prevenTAtive measure. But it's preventive, not preventative, care.



    Why Is It (5.00 / 2) (#56)
    by CDN Ctzn on Thu Nov 20, 2008 at 06:16:01 PM EST
    that the USA is apparently one of the few if not the only major country without some form of socialized medicine? The rest of the world seems to be doing quite well without the Health Insurance Industry, so why do we stubbornly cling to it? Is is somehow woven into the "we're number one!" narrative that's programed into us from childhood?

    I mean really, what makes socialized medicine so bad for us while other countries and their citizens thrive under it. Is it still the insane "Red Scare" thing?

    In case you haven't noticed, we're NOT number one when it comes to the healthcare of our citizens. We're not even close.

    But we are Numero Uno... (none / 0) (#67)
    by kdog on Fri Nov 21, 2008 at 08:50:20 AM EST
    when it comes to profit off of healthcare.

    No to begrudge anyone a little profit for services well rendered or anything, but I can't see where services are being well rendered...I'd say the majority of us feel screwed and are paying for the priveledge.


    Hoping we on the left are prepared (none / 0) (#4)
    by vicndabx on Thu Nov 20, 2008 at 09:05:48 AM EST
    to take an objective look at healthcare in the US.  Mandates are key to offering coverage to everyone regardless of their health.  I too often hear folks complain that those w/chronic illnesses have issues obtaining coverage.  I am sympathetic to these complaints.  However, just like any other business in the world, insurers can't assume all the risk w/o the possibility of catastrophic failure.  If anything, the recent events in the finance industry should provide some valuable lessons on the issues associated with risk.

    Blue Cross used to be a not-for-profit (5.00 / 2) (#17)
    by inclusiveheart on Thu Nov 20, 2008 at 10:19:06 AM EST
    entity.  The fact that this is a for profit business at all is problematic to say the least.

    I used to work with a company that focused on brain cancer.  The average lifespan for someone diagnosed with brain cancer is six months.  One of the main obstacles to care for these patients - and not for nothing obstacles to improving outcomes - was the insurance companies who took the position that the cost of care was too high if amortized over the six month projected life span.  In other words, those extra days of life for someone were too costly and therefore they shouldn't receive care that might give them those days.  It is worth noting that that is an average and that the more we try to save these patients the more we learn and the more we improve that average - but if we just don't do anything and let people who have brain cancer die just because they're going to die anyway, then we won't ever be able to figure out how to beat it.  I have one friend from that time who is now a ten year survivor.

    So that's a stark reality in the for profit insurance industry.  Whereas in a not-for-profit model there is no need to prioritize sharholder value over patient health - nor is there quarterly pressure to keep profits higher in order to please the stock market.


    A recent article in NYT (5.00 / 1) (#19)
    by oculus on Thu Nov 20, 2008 at 10:34:04 AM EST
    (probably in the science section) discussed our again population, incidents of kidney failure rising, and how, even with government sponsored medical care for all, decisions must be made as to how much money to expend for older patients.  Scary.

    It might take decades, but (5.00 / 3) (#21)
    by inclusiveheart on Thu Nov 20, 2008 at 10:44:52 AM EST
    I would venture to guess that if we enacted a national healthcare system and started making sure that people who needed care got care earlier in life, that people just did simple things like had yearly check ups - we'd find that our overall healthcare costs would go down.  The objective is to stabilize the overall health and well being of the population by doing what we can to not only eradicate ailments, but also catching them earlier when they are easier, cheaper and quicker to treat.  

    Diabetes which is a growing problem especially amongst certain minority populations can result in huge medical costs for catastrophic care if it is not properly managed.  The minority populations often fall into the underserved category in our healthcare system and therefore often do not have access to the care that would prevent the catastrophic events that can result from diabetes - and when those events happen those are the people who don't have the resources to pay - so we all pay in the end anyway.  There is a better mouse trap.


    "Aging" (not "again") (none / 0) (#20)
    by oculus on Thu Nov 20, 2008 at 10:35:18 AM EST
    In addition... (none / 0) (#39)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 12:51:15 PM EST
    ...to the rising obesity problem amoung the young in this country, the frightening increase in diabetics, ect.  All of these things point to huge increases in the cost of providing health care down the road--no matter who's pocket it comes out of.

    Single payer would be helpful in this regard if we include a strong focus on preventative medicine to try and stop these issues before they become epidemics.  


    Meanwhile, Supreme Ct. of (none / 0) (#53)
    by oculus on Thu Nov 20, 2008 at 03:55:15 PM EST
    Canada holds obese airline passenger is entitled to two seats for the price of one ticket:


    And I recently read, probably on AP, criminal detainee was released from custody due to obesity. I see a huge rush in pro per prisoner litigation stemming from this ruling!  First they feed us starch, then we get overweight, then--get out of jail free.

    Lastly, David Sirota opines Daschle will involve state governments in any health care plan he backs.


    There is a whole list of things... (none / 0) (#54)
    by MileHi Hawkeye on Thu Nov 20, 2008 at 04:06:05 PM EST
    ...that will have to be up-sized for the obese if trends continue--from toilets to hospital beds to MRI machines.  I guess airplanes and prisons are no different.  

    At least this may limit the (none / 0) (#55)
    by oculus on Thu Nov 20, 2008 at 04:13:35 PM EST
    obese passenger spill-over effect.  

    Blue Cross continues to claim it is a (none / 0) (#64)
    by MoveThatBus on Thu Nov 20, 2008 at 08:50:16 PM EST
    not-for-profit company, but it certainly manages itself and its spending like a profit company.  When it shares its profits, it only shares with the non-exempt employees rather than the membership (premium payers).  It is a serious problem...because all exempt employees are incented to manage costs to their personal wallets.

    That's why it shouldn't be (none / 0) (#62)
    by sallywally on Thu Nov 20, 2008 at 08:41:29 PM EST
    a business.