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Real health care reform requires a cultural change in how we view health insurance
Posted by: McQ on Wednesday, October 03, 2007

John Stossel makes an important point about health care reform:
Candidates for president have plans to get more people health insurance. Some would compel us to buy it; others would use the tax code to encourage that. Regardless, insurance is the magic that will solve our health-care problems.

But contrary to conventional wisdom, it's not those without health insurance who are the problem, but rather those with it. They make medical care more expensive for everyone.

We'd each be better off if we paid all but the biggest medical bills out of pocket and saved insurance for catastrophic events. Truly needy people would rely on charity, not government, because once government gets involved, unintended bad consequences abound.
I think that anyone who really puts any thought into this and reviews the history of government involvement in areas it doesn't belong would be hard pressed to argue against Stossel's final point.

Back in January Arnold Kling wrote an article entitled "Insulation vs. Insurance" at Cato Unbound. In it he said:
The health coverage most Americans have is what I call “insulation,” not insurance. Rather than insuring them against risk, most families’ health plans insulate them from paying for most health care bills, large and small.

Real insurance, such as fire insurance, provides protection against rare, severe risk. Real insurance is characterized by:

– low premiums
– infrequent claims
– large claims

American health insurance—including employer-provided insurance and Medicare—is the opposite. Families typically are paid claims several times per year, often for small amounts. Premiums are high—the cost of providing insulation often exceeds $10,000 per year per family. However, most families pay these premiums only indirectly, through taxes and reduced take-home pay from employers.

Real insurance would pay for treatments that are unavoidable, prohibitively expensive, or for illnesses that occur relatively rarely. Instead, insulation reimburses even relatively low-cost services, such as a test for strep throat or a new pair of eyeglasses. Insulation pays for treatment even if it is commonplace or discretionary.
In fact, what most Americans have isn't really "insurance" in the traditional sense as Kling points out. What are the real effects of this sort of a system?

Kling answers:
From an economic standpoint, insulation is both inefficient and inequitable. It allocates too many resources to health care, and it includes regressive subsidies that flow up the income scale.

Insulation leads people to over-consume health care services. Americans make extravagant use of services that have high costs and low benefits. Many studies that compare groups with similar conditions show that those with the largest levels of health care spending fare no better in terms of outcomes than those that spend less.

Insulation is also inefficient because of the large taxes that it requires. Payroll taxes support Medicare. Income taxes support Medicaid. Moreover, income tax rates are higher than they would be otherwise, because employer-provided health insurance is a deductible expense for companies but is not taxable income to employees. Taken together, higher payroll and income taxes to support insulation discourage work and thrift, leading to what economists call a “deadweight loss” to the economy.

Insulation also is inequitable. Millionaires on Medicare have their treatments paid for by taxes on low-income workers. High-income earners derive relatively more benefit than low-wage workers from the tax exemption of employer-provided insulation from health expenses.
The obvious point here is the product we all call "health insurance" isn't insurance at all in the traditional sense. Kling, and Stossel, argue that true health care reform should start with changing the product from "insulation" to true insurance:
Real health insurance would pay claims to people who come down with expensive illnesses. Typically, these expenses accumulate over a period of years.

[...]

Real health insurance would not require high premiums. Fewer people would be discouraged from obtaining insurance by sticker shock.
But as Kling points out, it is a cultural objection to be overcome. We're just used to insulation vs. insurance in this particular arena.

Stossel:
If people paid their own bills, they would likely buy high-deductible insurance (roughly $1,000 for individuals, $2,100 for families) because on average, the premium is $1,300 cheaper. But people are so conditioned to expect others to pay their medical bills that they hate high deductibles: They feel ripped off if they must pay a thousand dollars before the insurance company starts paying.

But high deductibles may be the key to lowering costs and putting you in charge of your health care.
And to me, better, cheaper and more efficient health care can be achieved, but only if the consumer is in charge of the buying decision. Both Kling and Stossel discuss that in their articles and both are well worth reading completely.

If we're really serious about health care reform, this seems the most reasonable and liberty-friendly solution out there.
 
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This "phony soldier" thing is sucking the air out of the attempt to generate outrage over the SCHIP veto.
 
Written By: Neo
URL: http://
In Taiwan the co-pay to see a doctor for a minor illness like a cold is US$ 3.00.

Guess what? In Taiwan, you see a doctor for every cold you get, and start seeing him at the first sign of a sniffle.

Beyond this, you can only get 2-3 days of medicine from the doctor (and yeah, its basically over the counter medicine coming to you in prescription form) so you have to come back over and over until your cold is better. This is to save money on medicine.

Did I mention there are no appointment times, and that you have to wait in line to see the doctor? Thus when my child is sick, I have to waste about 2 hours every 3 days for about 15 days. (The doctor makes sure you keep coming back forever, as they get a payment each time you visit.)

Yes, I have brought Dimetapp back from the States to avoid this, but my wife is convinced that only the doctor’s medicine truly works and thus I am stuck.

Oh, and everyone buys their own private cancer insurance, because the state run system doesn’t pay for the good cancer drugs. (sound familiar?)

Another major problem is that there are no malpractice lawsuits at all. GREAT! Except that means doctors routinely screw up and you are forced to doctor hunt. (I guess that’s good that you are allowed to choose your own doctor, though.)

Then again, the pre-natal care was awesome with ultrasounds every month.
 
Written By: Harun
URL: http://
I’ve long argued (to the two people that listen to me :) that the major problem with health care is that the government does not tax employers when they offer health insurance to employees. So, if I want to pay an employee, but not pay the FICA/Social Security tax, and the employee doesn’t want to pay income tax, what do I do? I offer them health insurance. Then, to pay them even more, tax free, I start offering health cost insulation (I like the terms "insurance" vs. "insulation" by the way). With the current tax code, it is win-win for the employer and employee. Because of this setup, people no longer pay for their own health care and act accordingly.

So, I am not even sure we need a complete culture change. That will come naturally if we have people actually pay for their own health care, whether through paying for the "insulation", or paying for it directly. We just need to remove the tax exemption for employers paying for employees health care. Then again, we probably need a culture change to allow that to pass.
 
Written By: Clark Taylor
URL: http://
My company started last year to go to deductibles rather than co-pays. They also shed the referral from primary as well. The latter seems to have caused my primary to go into survival mode, as the office is now almost empty when I do go in.
 
Written By: Neo
URL: http://
Finally someone is pointing out what I have always said: What people refer to as "health insurance" is really prepaid subsidized medical care. I want to be able to buy health insurance in the same way that I buy car insurance. I get to choose the deductible, the coverage limits, and I pay the little stuff out of my own pocket. Somehow people manage to budget for cable, telephone, food, rent, car repairs, etc..., just do the same for medical costs. Then have a disaster policy that only pays out after you hit the deductible. The difference between medical and car coverage is that medical problems can become chronic and require long-term care. Smart people can figure out ways to handle this.
 
Written By: Paul
URL: http://
So I had a thing on my face, a sweat bump the dermatologist called it. Wouldn’t go away. I said Take it off!. He says No, if I take it off it’ll cost you $250 plus $125 for the biopsy. Patience, says he, it will go away.

My insurance would have paid for it, but $375 seemed a little high. So I went home and whacked it off with a sterilized razor blade. These are the kind of smart, smart decisions we cannot count upon our fellow insurance pool members to make. So I’ll pay for the next guy to have his sweat bump removed and biopsy-ed. Disincentive much?
 
Written By: spongeworthy
URL: http://
OK, I’m going to give you a partial pass on this because I tend to agree with the point you are trying to make but find your example to be poor. (OK wrong, but at least Dale didn’t post these numbers:-) your post claims:
" If people paid their own bills, they would likely buy high-deductible insurance (roughly $1,000 for individuals, $2,100 for families) because on average, the premium is $1,300 cheaper. "

That would be ’wrong’ for me but most people are stupid so unfortunately it’s probably true - review those numbers and consider a few points:
- if you are single then those numbers aren’t correct because there is no ’family’, in fact what happens is the premium still winds up cheaper then the full deductible.
- If you are a family and even 1 person in your family has a chronic condition (MS, diabetes, any of another host of diseases that are fairly common,) or is pregnant or if you have a young (under 2 year old) child you will easily hit that deductible with no effort.
- if you have more then 2 children you can easily expect to hit or come damn close to hitting the $2,100 limit or more appropriately the $1,300 limit because that’s the point where your failure to pay the premium costs you money.

Fact is that insurance with a high-deductible to start with +10% after that is a sucker bet, most people picking it will pay more.

While I don’t disagree that billing is where our problems in healthcare are this post doesn’t really address the issues. I sometimes think that the majority of people discussing healthcare have never faced things like major surgery because they don’t discuss the real problems - which is the billing system.

Next let me establish a little example - I saw my doc for my quarterly appt. (I have a chronic condition 4 doc visits per year, medication, blood tests and urine tests every quarter for that condition which will eventually kill me. Yeah I can never change jobs/get private insurance welcome to the world of millions of Americans with insurance.) The doc noticed a swelling in my neck, next visits off to testing on the thyroid, results are suspicious off to a specialist for a biopsy, biopsy is suspicious, off to the hospital for a second biopsy. (all of which resulted in bills that you wouldn’t consider catastrophic but which more then exceeded the numbers in your posting.)

Biopsy results are again suspicious off to surgery for removal of the thyroid because of potential cancer. This would be a catastrophic event. (Final determination not yet cancerous but long term, add another maintenance med since without a thyroid you die if you don’t get medication.)

I’m not here to discuss any of the details of all that but to talk costs...

I know them because in our broken system everyone involved billed ME. Even though I happen to have very good insurance I get to see all the bills - unlike an HMO I see just what everyone is trying to bill, what get’s paid and where people get their hands slapped. So yes they also billed my insurance but a year later - there were still unresolved bills - why because medical billing is completely broken.

My hospital initially billed a little over $7K for my afternoon surgery which required a single night stay - I was out before 8AM. My wife was at the same hospital within a very recent time of that surgery, due to issues although surgery wasn’t involved her time in the hospital was around 3 days, the bill $4K... but you say - hey it didn’t involve surgery - you’re right but those numbers omit the surgeon, the assistant surgeon, all testing etc. What happened - well the insurance company immediatly shot down the hospital’s claim they recognized that the surgery & overnight should cost WAY less then what the hospital billed. The hospital countered but the insurance company had someone who knew which items just couldn’t possible apply to my case and they were removed and suddenly the price was less then my wife’s stay. Next the insurance company which had a contract with the hospital just essentially told the hospital that while the "List" price might be 10x, they were only paying 4X to 6X on each of the items immediately reducing the corrected bill by another 50%. In the end my final bill prior to insurance paying anything was 25% of the original (and I paid my 10%)

The challenge - although I went to a single surgeon who scheduled and did my surgery I was then billed not only by the hosptital, but separately by the surgeon AND separately by the asst. surgeon, and the anestesiologist, and the lab and the pathologist
- none of whom I had ever met, agreed to or anything else (billed separately primarily because of liability issues - which illustrates a stupid fact of our legal world).

Plus my insurance decided initially that they couldn’t justify the asst. surgeon or anestesiologist so they just sent those bills on to me. (I challenge anyone to allow someone to cut open their throat (about 4 inches) and remove a vital organ without anestesia.) That took literally months to resolve while both groups pursued me with bills. The lab - wasn’t approved by the ins. company so there was a huge battle because of course the insurance company was looking at paying ’list’ price for the lab’s services which thoroughly pissed them off since they knew only s*ckers pay list...

The problem in healthcare isn’t people’s insurance it’s billing. Fix billing - in any other business if I charged you 50% more just because of your credit rating people would scream - but they don’t in healthcare (note I’m not saying people don’t charge more based on your credit - I’m pointing to the 50% #). There are alot of issues in healthcare - and myths (one huge myth being that having people go to the doc more often is cheaper - review why I had surgery... had I not seen the doc I might be dead instead and that’s much cheaper not better just cheaper.) The fact is any review of healthcare needs to first address billing then we can start to address how people can get healthcare. Reality is I watch every doc visit for my family get reduced by 50% because I have insurance - ie. good credit.

Now here’s the thing my surgery wasn’t that uncommon. The fees if standard shouldn’t have caused this many problems. An HMO patient would have waited literally weeks while the insurance company tried to estimate and prevent elements of the care. If instead the hospital/surgeon walked in and said "$5K taxes and title included if you take it off the lot tomorrow" - which is how our other for profit businesses work, everything would have been much simpler. Healthcare should be billed that way for everything except emergency room visits.

Medical billing is so broken it’s scary - I was sent to collections for a $.03 (three cent) balance (they didn’t bill me - would’ve cost too much) I’ve gotten mailed bills payable by mail only for less then a dollar - it’s insane. No other business (and we made healthcare a business) would work this way.

Want a solution, consider: Require my insurance company to pay bills and full and then have them bill me for my portion of the bill. This reduces everyone’s costs (has a bunch of issues I haven’t discussed but imagine if our current ’health insurance’ became what it’s main role is - ’payment insurance’.) Then re-start the discussion of health insurance from there - don’t pay your payment insurance carrier who is paying all the different billers - well now you do have a problem...
 
Written By: BillS
URL: http://
lost somethings in reviewing preview and not getting my changes updated - two notes:
added a comment that I’ve both been without insurance and on an HMO and would never want either again.

rewrote last paragraph:

Want a solution, consider: Require my insurance company to pay bills in full and then have them bill me for my portion of the total bill. This reduces everyone’s costs (has a bunch of issues I haven’t discussed but imagine if our current ’health insurance’ split out one of its main roles - ’payment insurance’.) Then re-start the discussion of health insurance from there - don’t pay your payment insurance carrier who is paying all the different billing entities - well now you do have a problem... but it won’t impact everyone’s healthcare and take a lot of emotion out of the equation… wait till you start picking your ‘payment insurance’ based on it’s cost of insuring participant payments only.

sorry for the update.
 
Written By: BillS
URL: http://
BillS: You might consider getting a blog, typing a summary, and pasting a link. Then you can edit whenever you want.

Totally friendly suggestion, this isn’t my blog.
 
Written By: Jeremy Bowers
URL: http://www.jerf.org/iri/
I’m gonna quote myself:
When Medicare was being pushed in the ‘60s, the government claimed it would never set doctors prices. But Medicare had the result of providing doctors with “rich” patients who could pay large bills without blinking and without any incentive to shop for lower prices. So doctors did what they did before Medicare, they charged the “rich” patients more. And when the government found out it was paying “too much” (more than non-government funded patients), it called this “Medicare fraud” (previously when real rich people paid more than the poor it was called “charity”). And, since the government had no inherent means of determining the “right” price, it put in place regulations that doctors had to contend with. Doctors than banded together and hired staffs of business specialists (HMOs) to help the doctors sort out the government regulations. The result was higher medical prices all around, and a call for more government involvment in the medical system.
Also essentially applies to medical insurance.
 
Written By: Don
URL: http://
McQ: Isn’t the approach you’re describing compatible with Health Savings Accounts? The patient has a high deductible and is responsible for paying his own routine expenses (like eyeglasses and mole removals) and other bills up to the deductible amount, and insurance kicks in for things that exceed the deductible. Instead of paying higher premiums to get a lower deductible, the individual can deposit an amount equal to the higher deductible into a private savings account. These deposits are tax-deductible. Payments for medical bills come out of the savings account and, once the patient has paid a total that reaches his deductible, then insurance kicks in.

Patients who have little or no health care bills can keep the money in their account and let their annual deposits build up over the years. A relatively healthy person making the maximum savings deposits annually could accumulate quite a little nest egg. The bigger the savings, the better able the individual is to pay for expensive care that is not covered by insurance. An individual who has made sure to deposit the maximum amount into his HSA for at least a year or two and who does not withdraw funds should always have enough money in the HSA to cover the deductible, so he is really not at great risk. That is, if the deductible is $2500 and he deposits the maximum allowed amount for two years, the HSA will have $5000 (earning interest), so even if he doesn’t make additional deposits the account should still have enough to cover a $2500 deductible in the future. And, if he does spend the deductible amount most years because of health problems, he can still make annual deposits to cover the deductible so he won’t fall behind. Overuse of medical care is thus discouraged (well, it would be for me; I would rather have money in the bank), so a healthy person who is not a great consumer of medical care should do quite well with an HSA.

Individuals can get a tax deduction for their HSA deposits, but they cannot deduct premiums for privately purchased insurance, so I certainly think that HSAs are a great choice for people who must buy their own insurance. HSAs can be funded wholly or in part by employers (but I don’t know who gets the tax deduction and who owns the money in the HSA account). Furthermore, the money in an HSA can also be left to the individual’s heirs, which beats many government-designed programs, like Social Security. Insure Blog (http://insureblog.blogspot.com/) has a number of posts on the subject, and the fellows who write this blog are very much in favor of HSAs.

As I see it, the one big weak point is that an individual might fail to deposit the maximum allowable amount each year, whether through irresponsibility or lack of funds. This might leave him short of funds for current medical care, as well as a loser in the long-term savings benefit for old age. That old bugaboo called "personal responsibility" is the heart of the HSA program. And isn’t that what you are advocating?

I know that bloggers on this site have written opinions that disagree about HSAs in years past, but I don’t remember which side you are on. And I also believe that the particulars of the HSA program have advanced over the past several years, so I would appreciate it if you would give us some updated discussion, particularly in regard to the points you have raised in this post.
 
Written By: pa
URL: http://
Huh?
 
Written By: Xrlq
URL: http://xrlq.com/
I see three principles at play here.
 
Written By: Xrlq
URL: http://xrlq.com/
The first is that insurers have to make money, so on balance, it’s a losing proposition.
 
Written By: Xrlq
URL: http://xrlq.com/
The second is the over-consumption issue that others have raised. I tend to discount that one myself, as most people I know are loath to visit the doctor, and routinely forgo visits they probably should make even when the co-pay is low - though admittedly, hypochondriacs do exist. The third, however, cuts the other way: increased bargaining power. HMOs are essentially service contracts, not insurance, but like other service contracts (e.g., home warranties) they can be a bargain. Doctors hate them, for precisely that reason: they effectively enable large numbers of patients to collude and strong-arm them into accepting lower prices from everybody than they could otherwise fetch from most people (not all, but plenty to keep them in business) on the open market.

Do HMOs, on balance, save us money or cost us? I don’t know, and I’m not convinced that Stossel does, either.
 
Written By: Xrlq
URL: http://xrlq.com/
OK, now can someone explain why I couldn’t post that series of comments in a single comment without having the site tell me I had posted a blacklisted word?
 
Written By: Xrlq
URL: http://xrlq.com/
Huh?

I see three principles at play here.

The first is that insurers have to make money, so on balance, it’s a losing proposition.

The second is the over-consumption issue that others have raised. I tend to discount that one myself, as most people I know are loath to visit the doctor, and routinely forgo visits they probably should make even when the co-pay is low - though admittedly, hypochondriacs do exist. The third, however, cuts the other way: increased bargaining power. HMOs are essentially service contracts, not insurance, but like other service contracts (e.g., home warranties) they can be a bargain. Doctors hate them, for precisely that reason: they effectively enable large numbers of patients to collude and strong-arm them into accepting lower prices from everybody than they could otherwise fetch from most people (not all, but plenty to keep them in business) on the open market.

Do HMOs, on balance, save us money or cost us? I don’t know, and I’m not convinced that Stossel does, either.
 
Written By: Dale Franks
URL: http://www.qando.net
It worked for me, X.
 
Written By: Dale Franks
URL: http://www.qando.net
It was the "H" word... :)
 
Written By: Scott Jacobs
URL: http://
xrlq: Doctors from my experience hate HMO’s because they directly impact treatment options and costs. As noted by my comment on not paying "list price" traditional insurance offers little additional money to the doctor, thus it impacts costs; but it makes it easier to make decisions since things don’t have to be approved. The doc who’s patient has traditional insurance can treat the patient without prior permission. In my experience doctors hate oversight way more than they are concerned about $$$, as noted by automated systems which require comments for certain actions that are traditionally filled with comments like "Because" or "Because I said so."

Jeremey: decided to take your advice and create a Bill’s Opinions blog: http://bills-opinions.blogspot.com/ eventually I’ll repost my earlier response there and link back.

btw - MCQ the remember-me feature makes adding the url to my comment sig a "challenge" (as in I can’t) - guess I need to go delete the cookies and rebuild it.
 
Written By: BillS
URL: http://


 
Written By: BillS
URL: http://
getting blocked on one paragraph - figured out it wasn’t the html for a link or the strong I had put on the names so going to try different sentences since I’m not sure which term I’m trying to use is blacklisted.

 
Written By: BillS
URL: http://
pa: your description is also similar to a
 
Written By: BillS
URL: http://
’s*lf*insuranc*’ model.
It’s not uncommon for companies to attempt this model in an attempt to manage costs. I don’t have a problem with that model but it is a very different discussion.
Not the value of ’saving’ for yourself is directly impacted by a reduction in savings if you are paying for insurance. The ins. becomes an annual cost that reduces your savings and you will only recover the insurance cost in a catastrophe.
 
Written By: BillS
URL: http://
it was something in the words,
self
-
insurance

when enclosed in single quotes.
 
Written By: BillS
URL: http://
Feature Request: Any chance preview could highlight any portion of text which is going to get a comment blocked?
 
Written By: BillS
URL: http://
I emailed Jon the original version of the comment, which compared insurers to c*sinos and insurance to gambling. He said one or both of those words was probably what got my comment blocked. I tried this comment with both words unedited, and then with gambling edited only, and it got blocked both times. Apparently, it’s OK with gambling, as long as you do it at home rather than at a c*sino.

I like BillS’s suggestion.
 
Written By: Xrlq
URL: http://xrlq.com/
The second is the over-consumption issue that others have raised. I tend to discount that one myself, as most people I know are loath to visit the doctor, and routinely forgo visits they probably should make even when the co-pay is low - though admittedly, hypochondriacs do exist.
The key aspect of medical "over-consumption" is consuming without regard to cost. No one shops around for competative healthcare, since no one pays for it.

Aside from that, I’ve taken my children to the hospital for things I probably wouldn’t have if I had to pay the full price.

 
Written By: Don
URL: http://
Just a question to ponder:

We believe in public education, even if we desire to see a voucher system, whereby every child’s education would be subsidized in the form of vouchers that could be redeemed at any accreditted school of the parent’s choice.

What about subsidized health care for all children? why not expand the SHCIP program to all children in a similar way, with health care for all children (albeit administerred by accreditted health-care providers of the parents choice) payed for by pooled government tax revenue?

Is there a significant moral difference between ensuring education for all children and ensuring health for all children?
 
Written By: Jimmy the Dhimmi
URL: http://www.warning1938alert.ytmnd.com
Is there a significant moral difference between ensuring education for all children and ensuring health for all children?
Personally, I don’t think is a significant difference, and I suspect that many on this board will agree.

However, in their agreement with the premise, they may suggest not that we SHOULD provide health insurance to all kids, bit rather that we should STOP offering socialist public education.
 
Written By: Captin Sarcastic
URL: http://
Is there a significant moral difference between ensuring education for all children and ensuring health for all children?
In the most fundamental sense, no. Both rely upon the confiscation of people’s wealth, so they are both theft.

As Captian anticipated, I’d ditch both.

But there are practicle differences between education and healthcare.

Currently a lot of the funding for education is local property taxes. I prefer this, ’cause you get to pay for your own school district, not so much someone else’s. No one is proposing to do healthcare this way, since that would mean rich neighborhoods would get better healthcare.

 
Written By: Don
URL: http://
Hey guys!! This is very important to take care of kids health and I think its wise to shop online for the best quality health products and plans at most discounted prices, for this visit my favorite shopping site Couponalbum.com..!!
 
Written By: Don
URL: http://www.couponalbum.com

 
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