I don’t think you’re following me. The Maximum Out-of-Pocket is set by the insurance company. The Health System (please note when I say Health System I mean the provider which can include multiple hospitals and clinics and etc.), may still have a Financial Assistance program that is independent of what the insurance company is doing. There are still several health systems that are not-for-profit. This means they often offer Charity Care, not just to Self-Pay patients either. A lot of Charity Care is based on ancome and assets and of course the balance of the bill.
The point is, there’s assistance beyond subsidies and insurance limits… Some, many, of the health care systems themselves work with the guarantor directly.
Any healthcare system for everyone is going to fail until we get single payer. The overhead of having 15-20 insurance providers requires so many specialists to fill forms, approve treatment priorities, etc that 10-15% of a healthcare office personnel is dedicated to insurance.
The other problem that is not being talked about is how so many people are not getting coverage until they have a problem. This is supposed to be mandatory. The fines are not sufficient in forcing people to have the coverage. If everyone had the coverage, the rates would be lower. It reminds me of a small segment of the population who doesn’t get car insurance. When they are caught, they “prove” they insurance by showing a monthly payment in court - and then promptly cancel again. The meager fine is so little, it makes financial sense to do this.
You are right and one of the biggest beneficiaries of their charity is people without insurance. In fact, I’d be willing to bet that a couple with 40K income and not much assets and no insurance that ran up a $50K bill with a hospital is going to be eligible for a lot more assistance, than the same couple with insurance who only owes $11,400.
That may not be the case anymore. The expansion of Medicaid, which you don’t balance bill, means hospitals were writing off less less to Charity Care… except they have to have write-offs in order to maintain a Not For Profit status. This means in some cases, maybe even many cases, you can have a low income with insurance and now qualify for some FA programs.
We have plenty of example of single payer in this country (VA, Medicare, and some state employee systems) and none are particularly cheap. The reality is that the US has a very expensive health care system, we pay our doctors and administrators a ton compared to most other countries. Our nurses and other skilled care are also paid well. We spent a lot of equipment. This is an excellent article on the structural reasons we have expensive health care. Single payer really isn’t going to change this.
Once spending is in the system, it’s hard to get rid of. I’ve already covered the political difficulties with using government power to take income away. But those aren’t the only problems. For example, in the middle of the last century, the U.S. decided that private or at most two-person rooms were best because they made it easier to control infection and to let patients rest. For decades, we built hospitals to this standard; when my mother was in the hospital for a complicated appendectomy, there weren’t even any semi-private rooms on the surgical ward.
Private rooms drive up costs in a lot of ways: They take up more space, you have to duplicate equipment, and because the nurses can’t see the patients, you need more monitors and/or staff circulating to make sure no one has stopped breathing. Basic hospital rooms in many other countries look spartan and overcrowded compared with what most Americans are used to, because they have more people and fewer beeping machines.
But even if we got a single-payer system tomorrow, we would not be able to do what those other countries have done, which is not build expensive single hospital rooms in the first place. Those hospitals were built over time, as funds became available and as the old buildings wore out. Trying to replace them all at once with semi-private rooms or wards would cost more than just sucking up the extra expense of the hospitals we have.
But yes one of the many problems with Obamacare is that it begs to gamed. I’ve mentioned when ACA first become law on my early retirement forum there were hundreds of 40 and 50 years olds that either retired early or were looking to retire early, with an average of ~one million dollars in investable assets, figuring out ways of getting their ACA subsidies. ACA is a terrific program for making it easier for wealthy people to retire early, but why taxpayers should subsidize this is beyond me.
I’ve been saving money by going with a catastrophic-only coverage. If I get a chronic illness like say diabetes I’ll get a better health plan. In the past, I wouldn’t have been able to switch plans because of pre-existing conditions.
Insurance companies have been seeing people sign up when they get sick and then cancel at an alarming rate.
In the example, I gave it is doubltful if make sense for the couple to get insurance. But if you take the same couple and make them living together, then it makes a lot of sense for them to buy two individual policy. There is huge marriage penalty associated with ACA.
Yes, before we go Single Payer, we need to address the supply side.
Medical School is very expensive. Mal-practice coverage is chasing away several specialties (mal-pratice like we have doesn’t really exist in other countries). We’ve talked a lot about drug expenses. There is often a nurse and general practitioner shortage. Rural areas are under-served.
And we should keep in mind, private insurance still exists in SP environments. When I received care in Japan… I paid cash, and not just because I was a foreigner.
What a bullshit article. I hate crap like this that purports to use statistics on gross health spending without talking about population growth. Hey news flash, The US population was 180 Million in 1960 and 316 Million today while the UK went from 52 Million to 64 Million. And no mention of baby boomers and their exploding senior costs or the excess cost of people without insurance getting their care in the emergency rooms.
Yes there are a lot of reasons healthcare increases but to dismiss Insurance costs between 10-15% as part of that excess ignores a large contributor.
Your examples of single payer aren’t really single payer because of the excess cost already baked into the system - the hospitals maintain insurance specialists and they don’t just tax the specific insurance companies. They bake it into their overall cost structure.
The EMR software also is excessively expensive because of all the interfaces to these companies. I have a friend who is a Mckesson specialists - the hospital she works at maintains a staff of 6 who are responsible for being available 24x7 just to answer questions on how to use the software so every doctor & nurse doesn’t have to be an expert.
If we don’t want single payer, then the only way to drive costs down is to get everyone to be a participant. The pool of healthy people is needed to keep costs down for everyone. As pointed out up thread, the last two years has seen an abnormally high number of new people joining who need above average care. That needs to normalize before we start to see any semblance of rates flattening out.
EDIT: Upon reflection, I was a bit harsh. I’m not trying to be harsh on you Strollen, I’m just irritated at the author of that Article because it just smells like one of those articles that is planted to forward an agenda and the data she uses is lazy. It is an opinion piece, just like my thoughts.
I need to layoff writing too much here lately as my tolerance for any articles or things I see online is really low right now. Too much bullshit. Not enough substance. This forum is a delightful change from that of course.
What the hell are you talking about? Off the 13 graphs in the article exactly two were total expenditures. The other 11 were per capita or growth rates or different reimbursement rates for the US vs other countries absolutely an apple to apples comparison
But where did you that idea that 10-15% of the health care cost are because of private insurance?. There are a legion of people employed by the medicare operation division of HHS who’s job it is to figure out how much to pay a specific hospital or doctor for a specific procedure. That’s also true in England and Canada. That function doesn’t magically disappear just because we go to single payer.
Even if you are right that 10-15% of the hospital employees are involved with insurance that in no way means that costs are that much. The insurance clerks are making $40K vs $120K for an experienced nurse $250K for doctors and $500K for surgeons and top administrators.
All of that pales compared to a $10 Million dollar MRI which typical US hospital have two and most international hospitals have none. (I just attended an investment pitch for an MRI add-on product there are almost twice as many MRI in the US as the rest of the world combined.)
There aren’t any magic bullets in this search for affordable health-care and pretending there are doesn’t do anything but set up false hope.
I’m not going to go through all the graphs, but just look at the first two, per capita & % of GDP.
Per capita, or per person spending, just says “hey look how much we spend on healthcare”. Healthcare is what exactly? How are you measuring this? Who is spending? Where did they spend it? Preventative, Operations, or the last 1 year of life? Are prescriptions included? This is what I mean by lazy numbers. It’s a pointless graph with pointless information.
Next we look at % of GDP. Why is how much a country outputs a good comparison to healthcare costs? You might as well ask how much healthcare do we spend as a consumption of bananas.
I agree there aren’t any magic bullets, but you have to whittle down all the costs associated with healthcare if you want to lower costs and just off the top of my head:
Health Insurance
FDA oversight on drugs (which isn’t all bad, but we’ve got to streamline this)
FDA compliance (this is for all the hoops companies have to jump through for Class 1-3 of medical devices).
Malpractice Insurance
Transparency of costs. Force prices to be up front like when I go get my oil changed for my car. Impossible to have competition
Doctor graft & corruption (I could tell way too many stories)
I was in healthcare for 5 years, doing class 2 medical devices, and my FIL was a VP of Epic healthcare for many years. The stories he tells. The 15% of insurance costs is indicative of any doctor’s office. Take an medium size 100 person medical practice that employs 10 doctors. They have 90 support staff - 15 of which will be insurance specialists.
I’m just dropping in to say it warms my heart to see such a heated discussion about actual policy competing with the horserace threads. Window into a better election where the two candidates were actually arguing over topics like this.
That sounds perfectly reasonable 15 people out of 100. Certainly, some of them could be eliminated if there was only one payer as opposed to 1/2 dozen all with their different rules and different coding. Probably a 1/3 maybe 1/2. But it is worth doing the math the 15 insurance clerks make roughly $40K on average ($20/hour) so their total cost is $600K plus benefits. Even if it is a bunch of internist and couple specialist the doctors are making on average $250K so $2.5 million in salary. Eliminating the 7 clerks is $280K in saving, cutting the physicians reimbursements by 10% which would still make them much better paid than any country but Australia (one of the charts in Megan’s article) is $250K.
But the bigger point in Megan’s article is that US has a different cost structure than the rest of the world.
Most other countries have a lot of moderately well paid medical professionals, a big poorly support staff but not a lot of the equipment. The US has slightly smaller number of very well paid medical professional, a big poorly support staff, and a ton of equipment. Eliminating insurance at best case gets rid of a few percent of the total costs and boatload of middle-class 40-50K jobs that don’t need college degrees.
If you were in the medical device industry you know that the market for leading edge (i.e. expensive devices) is really the US and a handful of international teaching hospitals.
In many ways, the US medical system is like the US university system we have lots of additional costs that don’t produce a lot benefits. Out kids want nice dorms, lots of counselers, and climbing walls. We want semi-private hospital beds with the latest equipment, access to knee and hip replacement with no waiting and doctors want to make a lot of money.
The problem is to get those healthy people to not do anything possible to avoid insurance, you need to make the healthcare reasonable in cost.
This is why it’s a failed market. This is why a taxation system and single payer is probably for the best.
If you need to keep free-market insurance- change how subsidies work so that caps are income based so older people making just above the threshhold don’t get gouged so hard.
Fixing the thing on the margins could do some good.
It’s the government payors that cause the most complications. You realize that we’d still have physician offices, they’d still require payment and we’d still have to find a way to allocate finite resources. A single-payor system doesn’t mean physicians can do whatever they want and get paid for it. We have the system we have today largely due to the fact when the government payors did do that… they experienced large amounts of fraud.
The gold plans seems to be targeted at people who know they have health issues or expensive medications already. I can’t imagine paying those prices as a “just in case”.
We’re on silver, but only because we know my wife will be on her $1300+/month meds for at least another year. Without known medical expenses, I’d be on bronze or bronze+ with a few grand moved in to the HSA.
