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1. http://gallery.hollywoodtheater.org/224704503/ botherfrigidstraddle

2. //Gadfly, I’d be willing to bet that you were “played” a little too.//
   I think so, too, because the doctor had an interest in channeling business to his private clinic. I wonder how many other students this happened to…?
   I do hate learning about things “the hard way”. Why does the damage always have to be done first, lol. 🙂

3. //I’d also like to underscore that both of these problems relate to the fact I didn’t understand the insurance. In years since, I’ve tried to read insurance documents, but I don’t understand them (at least before I go through an experience that illustrates what the terms are). My reading ability is higher than average: I can’t imagine people who barely have a high school education being forced to be “responsible” for understanding their insurance. That’s not paternalism, it’s realism.//
   I know in the case I was referring to which was a similar situation involving a doctor who operated a clinic/day surgery operation as part of his practice, there was a deliberate attempt to mislead patients about likely charges. He was an in-network doctor in my insurance plan and I was under the impression that in-network doctors were bound to the insurance reimbursement plan. I expected to pay a deductible and co-pay. The procedure was pre-approved so I expected all other charges were covered. I asked for an estimate of total charges and they wouldn’t provide one. What I found was that if the patient signs a document accepting financial responsibility for charges not covered by insurance that means that if that doctor charges the insurance company more than the allowable rate, the patient is responsible for making up the difference. I’d never had an in-network doctor play that game before. I expect a few games with car repairs, but I don’t like it when doctors run their businesses that way. Gadfly, I’d be willing to bet that you were “played” a little too. The guys that open their own mini-hospitals are very focused on the profit factor. The next time I run into that conflict of interest, I’m shopping for another option and won’t do anything without a written estimate of charges and a comparison with the insurance “allowed” charge schedule.

4. //your mistake– not asking how much?//
   I’d never been billed for anything else out of the grad school medical center, so why would I ask? By the way, I got dunked for another few hundred dollars later when I didn’t file my claims on time. While that sounds like a laziness penalty, I was sick at the time. So the problems caused by my medical condition were exacerbated by a financial penalty while the insurance I was paying for got an excuse not to pay the pharmacy bills.
   I’d also like to underscore that both of these problems relate to the fact I didn’t understand the insurance. In years since, I’ve tried to read insurance documents, but I don’t understand them (at least before I go through an experience that illustrates what the terms are). My reading ability is higher than average: I can’t imagine people who barely have a high school education being forced to be “responsible” for understanding their insurance. That’s not paternalism, it’s realism.
   //inflate the price of insurance because of the supposed value their due diligence process adds.//
   Not to mention the sheer cost of clerks and book-keepers to push paper.
   //antibiotics for their sniffles//
   I’d like to think like a market economist and assume there would be a big consumer revolution if people had to pay $70 a bottle for medication (on top of $100 for the doctor to prescribe) every time they had the sniffles. But, being a pessimist, I envision the U.S. turning into a third world country, with sickness and suffering overflowing in the streets and epidemics spreading like wildfire. Meanwhile, the uberclass just agrees to pay the $170 and revels in the additional distinguishing mark of being able to afford Sniffle-Be-Gone.

5. Sue said: “A lot of us would rather have wider access to a basic system than limited access to one with all the bells and whistles”
   What’s basic and what’s “bells and whistles”?
   Insurance should really be reserved for the big less common events, like cancer, that require expensive or long-term treatment. But most people then don’t see the benefit most of the time. They want “basic” care for everyday problems. So they get antibiotics for their sniffles, and get stiffed on their radiation therapy.
   Auto insurance doesn’t cover wear and tear or routine maintenance. Health insurance shouldn’t either. Deductibles should be high enough that people rarely exceed them. Then the money will be there for the medical disasters, where its really needed.
   Harvey

6. //Healthcare system transformation ought to include increased personal responsibility and a further departure from the concept of “paternalistic” medicine.//
   I couldn’t agree more. The problem is that a lot of health care providers and insurance companies like the paternalistic focus because limited choice and consumers divorced from price shopping translate to higher margins. Coincidentally, I’ve seen an example similar to Gadfly’s and it also involved a doctor with his “own” facility. He made patients sign a financial responsibility statement indicating that they would pay any charges the insurance company didn’t, but the office was just representing that this was to cover insurance deductibles and co-pays since the co-pay amount was billed later. He wouldn’t give upfront estimates. He was billing at about twice the allowable rate for his procedures and then billing the difference to patients when the extra charge was excluded by insurance. If you signed the financial responsibility statement, you apparently opened the door to allowing that practice. Eventually he closed shop and moved out of town because his reputation for overbilling got around.
   Practices like these and the fact that many providers won’t quote upfront rates help preserve paternalistic attitudes. Right now I have a $2500 deductible and every charge has to go the insurance company and then get billed back to me. I’d love to simply walk in, get treated and pay the bill that day and have it credited toward my deductible instead of waiting for all the paperwork to process–and in theory there is no reason why a provider couldn’t have a billing system that generated pricing in line with each insurer’s rate system right in the office. There is cost and waste in that process because it adds administrative time and receivables “wait” time. I’ve never really understood why insurers wouldn’t want to move toward that type of system, other than the current system allows better ability to deny claims and inflate the price of insurance because of the supposed value their due diligence process adds.

7. gadfly-
   your mistake– not asking how much? and not understanding the relative risks of waiting versus going ahead with surgery.
   doctor’s mistake– not explaining the above.
   Healthcare system transformation ought to include increased personal responsibility and a further departure from the concept of “paternalistic” medicine.

8. Another part of the hidden costs problem is that even with insurance, you can end up being surprised with a big bill after the fact.
   In grad school, I hurt my knee in a karate class. My knee troubled me enough to go to school medical center. A doctor found a fairly small cyst in an x-ray. He offered knee surgery (done by himself at his own private facility – he only worked part time for the school). I said “sure”, and I didn’t give it a second thought because I was insured through the school, and I figured insurance would pay for it. To this day, I’m not sure it was necessary: the cyst was small and might have gone away by itself. But I agreed to the surgery. The doctor never discussed the cost with me. Afterward, I got a bill for about four thousand dollars, and insurance only paid for part of it. That was a large bill for a grad student living off of fellowships and piecemeal research jobs.
   I would never have agreed to the surgery if I had been informed of the out-of-pocket cost. On the other hand, if I had chosen to tough it out, the problem might have gotten worse. Let’s say it was a problem that could have ultimately crippled me if I hadn’t treated it in time. Then my initial prudent decision to save a few thousand bucks would result in a huge social cost when I end up on disability.
   This is why I don’t think individual “rationing” is any better than socialized “rationing”. The thrifty individual can end up costing society more in the end. I’d rather that the costs of health care be shared, and the need for health care be determined by medical professionals, and then have some oversight to prevent price-gouging.

9. At least in Massachusetts and CT it’s community rated. A lot of people here don’t realize that in most places it’s medically underwritten.

10. //Most believe that food and shelter are more basic than healthcare. Should the government require that supermarkets carry certain brands of food? Perhaps they should dictate how the stores display their items so that it is easier for certain customers to find what they need? Since food is so important and it is unfair that some people cannot afford to shop at certain stores, perhaps those stores ought pay a penalty for their exclusivity? //
    Let’s imagine that grocery shopping were like our healthcare system. First, there would only be a few large food distribution chains plus a range of small specialty stores. If you worked for the government, were retired, worked a large employer who paid for food insurance, bought your own food insurance (if you could find a company that would sell you insurance) or were low income in a government-backed program you would be issued a card that told you what your co-pay and deductible were. You would go in and shop. Depending on your program aisle monitors might tell you that some aisles were off limit for your shopping. There would be no prices displayed, but with a card you’d understand what your maximum liability was likely to be. You would pay your co-pay at check-out but the end amount you owed would be dictated by the prices negotiated through your insurer which could change at any time. If you didn’t have a card, you could still shop at some stores. You would need to pay in full in checkout but wouldn’t know exactly what the cost would be until you were rung up. If you couldn’t pay today, but had income you would be billed monthly–you would get no refunds once you filled your cart and remember you won’t be told the pricing beforehand–some Aisles will be labelled “very expensive” or “basic” to help you understand some cost options. Obviously if you are paying as you go, you need to limit your store trips. If you failed to pay for groceries on time your house would be repossessed. If you had no assets to repossess and couldn’t pay your costs would be billed to the other cardholder accounts and the pay-as-you go crowd–in essense the system would reward you for not having assets because you would be able to get food free. Specialty stores would check your card before deciding whether to let you enter. If they didn’t like the amount your card company paid, they could refuse to serve you.
    That’s our current healthcare system and it isn’t a free market. Consumers have little influence on price. Deregulating a market that isn’t a free market, will only make things worse. We are transitioning from a market where the primary health care insurance mechanism source is changing from employers to individuals, but there is no solid transition path to catch people who covered in one system and aren’t welcome in the individual market. In theory, it isn’t cost effective to privately insure those individuals, but there is really no free market that they can competitively shop in. So the current solution is just ignore those growing numbers. The best way to reform healthcare would be start by looking at other systems. Right now we like to criticize single payer or socialized medicine, but what we should do is look at all systems. What elements are working and what aren’t? Are their free market systems that deliver affordable health care and how could ours change to get that way? What services are really needed and which should be cut? Does price regulation work (for instance, do we pay more for pharma here to make up for what is not chargeable in countries with price controls?) Would it make sense to broaden some of the current networks that provide affordable healthcare. In short we need to take off the blinders and question everything and then build a system that works. Because the current system is becoming so expensive that no one without insurance can afford a serious illness and in the current market insurance companies can exclude those who seem risky. I don’t want free health care, but I also don’t want to pay taxes and higher prices that enable everyone else that fits in a “special class” to get healthcare while being priced out of the market myself. That’s what I see happening to many middle-aged in the middle class right now and it is wrong. We need better cost sharing across the entire system, elimination of stupid entitlements and streamlining of administrative processes. The closer the consumer gets to buying their own care, the more sane the system will become.

11. While conceivably it might be possible to favor some health system other than single-payer and possibly even to favor the U.S. status quo, anyone – ANYONE – who uses the term “socialized medicine” to disparage health care reform is clearly frivolous and arguing in bad faith.
    On the other hand, perhaps the time has come for health reform advocates to wrap themselves in the “socialized medicine” banner. After all, many terms, such as “Gothic” architecture, began as pejoratives but wound up being embraced by their advocates.

12. There is general agreement to the statement: “Does the US healthcare system need substantial reform?”
    The question — how?
    Every legislative mandate — most borne out of a good motive– raises costs for everybody.
    Do we want Congress to legislate every drug that should or should not be covered (eg. Viagra)?
    Is it reasonable to force physicians to offer translation services for ANY patient seen, regardless of language, at the physician’s expense (current Medicare regulation)?
    Should Medicaid be forced to cover unlimited transportation from home to doctor’s office or hospital?
    Most believe that food and shelter are more basic than healthcare. Should the government require that supermarkets carry certain brands of food? Perhaps they should dictate how the stores display their items so that it is easier for certain customers to find what they need? Since food is so important and it is unfair that some people cannot afford to shop at certain stores, perhaps those stores ought pay a penalty for their exclusivity? Perhaps the government ought to require that automakers only offer safety features at one level, since it is unfair that the 2005 mercedes has better safety features than a 1994 ford?
    All analogies have flaws, but the point is simple. Can the government do a better job at managing your life than you? If not, than decreased regulation of healthcare (ie. medicare, mandates, tax favored status of business bought insurance) may be the best answer. If so, then every year the lobbying group for every disease– all of whom have very valid needs– will find themselves competing at the steps of the Capitol.

13. On the MS issue, the best health care my husband who has MS has received has come from the VA. VA Health Care in our area is outstanding and it proves that government-run systems can work. More importantly, without VA he would be uninsurable and not undergoing any treatment because the current cost of drugs for MS exceeds $1000/month. None of our private, employer-based insurance programs were covering his drugs before we successfully got VA to acknowledge that his condition was service-related (he’d had an attack in the Army that was noted, but not diagnosed–neurological disease suspected but not confirmed–glad I kept a copy of that record). I’d love to understand why the stock price of pharma companies goes up after they announce a new MS drug. If these drugs don’t recover their costs (theorectically that’s why they have to cost so much), you’d think the stock prices would drop when they were announced.

14. //Why would you think Canada’s system is mediocre compared to the US?//
    I wasn’t implying that, just responding to the post that implied Canada’s system could be inferior. A lot of us would rather have wider access to a basic system than limited access to one with all the bells and whistles. You can buy any level of care in the U.S. if you want to empty your wallet and/or have access to to a good insurance program. I’d be surprised if Canada’s system would allow all the treatment possibilities found in our system based on the discussions I’ve seen. That doesn’t necessarily make it mediocre, just more common sense.

15. I have a friend who has MS. As soon as she graduates from college (Ivy League, BTW) she is seeking employment in Canada. She saw the way the health care system treated her mother, who also has MS, and doesn’t want fighting for health care to define her life.

16. Why would you think Canada’s system is mediocre compared to the US?

17. //”Outcomes” have many variables, and ‘gadfly’s’ medical care might be cheaper for him in Canada– but perhaps not necessarily better.//
    The issue a lot of us in the middle class are facing right now is that we are potentially facing an absence of affordable healthcare if insurance rates continue to increase as dramatically as they have over the last few years. I hate to say it, but if I were on welfare, I wouldn’t hesitate to seek care in an ER. However, as someone with assets I ration my care because I now have a $2500 deductible (which means I’m paying 100% for my medical care every year) and am aware that if I “discover” a ratable condition through accessing medical care I may be jeopardizing my ability to switch insurers if the premiums become unaffordable. My last insurance company raised premiums to $700/mo on a $5K deductible policy and the current one is $379/mo. The first one started out at $300 two years ago, so concerns about premium increases forcing me to switch insurers aren’t frivolous. Personally, I’d rather have access to mediocre care at predictable cost than a system where I’m gradually excluded from insurance options and become afraid to seek medical care because I can’t get a good feel for costs before treatment. For some of us the system is now that broken.

18. Matthew- I appreciate all of your statements. Statistics, of course, have a way of being interpreted and developed by people who wish to support a hypothesis.
    As I have said on my show many times– few are “satisfied” by the current system.
    One of the essential rules of scientific investigation is “association doesn’t mean causation”. Given the current system and stats you mention– one might say that the problem in the US is that we spend 15% of GDP and not 10%. Perhaps if we just decrease spending by 1/3, outcomes will improve.
    We all know it is not that simple.
    “Outcomes” have many variables, and ‘gadfly’s’ medical care might be cheaper for him in Canada– but perhaps not necessarily better.

19. //gadfly, would your technical skills make it possible?//
    In a more just world, sure. But since the only employer to make professional use of those skills isn’t a source of a recommendation, getting work in what I’m good at is out of the question. I’ve been “invisibled”. :-p
    I’d love to live in the UK. I spent the best year of my life there in college, and I’ve wanted to go back ever since. *sighs wisfully*

20. I think the other issue to take into account is expectations. When most working or retired middle class U.S. citizens rate health care or envision what their health care access should be, their expectations are based on the system most of us have grown up with which insulates the “insured” consumer significantly from costs and in many cases allows the consumer wide access to a broad range of care. We are able to afford to do that because we don’t cover everyone and more and more the “system” finds ways to “shed” people that use it excessively (unless you are in a voter bloc Congress or the Administration wants to cultivate or an elected official). When our “insured” look at systems like Canada or the U.K. we are shocked and appalled at what we see as quality of care issues because those systems actually deny care to people who aren’t likely to benefit long-term (Terry Schiavo wouldn’t have been on life support in Canada or the U.K.). They also wait list people for critical services (but we do this as well–the difference is that wait lists here are determined by geography and income, or by insurance administrative practices vs. a centralized authority and that means that most of the time denial of care in our system is off the radar screen). In short, people who have access to good insurance don’t want system changes that erode their benefits because many of them currently have the best care in the world at the least out-of-pocket cost to them. The problem is that sustaining that level of benefits isn’t possible without continuing massive cost increases. Employers react to this by laying off employees and increasing their employee share of health care costs (the public sector hasn’t done that well yet, but it will and then there will really be screams from government employees). As consumers take on more and more of the actual cost of our “Cadillac system” I think we will start to see some change in expectations. Four years ago, I thought our system was great and didn’t want any change and certainty no government involvement–back then my out-of-pocket cost for health care was about $10 a doctor visit and $250 in deductible liablity and my employer’s premium cost was $201 a month for me. Now that I’ve purchased my own insurance for four years, I think if we don’t change that 10 years from now the “healthcare” crisis will be all that anyone talks about because employers are shifting away from the idea of being the primary provider of health insurance, a lot of baby boomers are being pushed out of the insured workforce without a safety net and insurance and pharma have lobbied themselves into an unsustainable market. When people understand the end choice isn’t keep the market like we have today or not, but really something closer to do we want a system that ensures only half the country (and drops more every year) and lets the other half get care if they can pay as they go (and keep in mind pay as you go can be $10,000-$100,000 increments) or a have a system that provides a basic level of healthcare access which everyone contributes to at an affordable cost I think we’ll start to have some reasonable debates about change. Until then, the arguments will tend to be more related to how much quality of care erodes with socialized medicine or single-payer systems.

21. Erick–I actually listened to your show last night. Very professionally done and all that, but how about mentioning how many Canadians went bankrupt last year because of health care costs versus how many here? What about what your guest said about how excellent emergency care was, and compare that to the disaster of a system we call emergency rooms here? How about being honest and doing a rational assessment of the peer reviewed studies that I reference which tend to show that the US provides worse care in many aspects, rather than putting on virtual propaganda. And last but not least, is it a conincidence that about the fact that system dissatisfaction is higher in the US than Canada among patients and lower among doctors?
    Taking into account a balance of care access and costs, someone like the Gadfly it would CLEARY be better to be in Canada. For the rest of us it’s probably a wash. And this is all at 10% of GDP going to health care not 15%.

22. Monopsony — market with single buyer.
    Canadian physicians can lose their license if found to be providing “covered services” for a rate negotiated between patient and doctor.
    12% of Canadians have no access to a primary care physician. That number approximately equals the number of uninsured in this country.
    The Canadian Supreme Court– one of the west’s most liberal — found the system a violation of people’s rights (at least in Quebec).
    Few anywhere in the current US Healthcare system are happy (possibly insurers as they have no need to offer services for the elderly (the taxpayers do that) and now no need to offer prescription drug plans (the taxpaers are going to do that).
    For those interested in hearing a discussion about how government control over healthcare payment rates — regardless of whether doctors are state employees– amounts to forced stealing of intellectual property, please listen to my show archives from June 26th.

23. gadfly, would your technical skills make it possible? I’d love to move abroad–to the UK or New Zealand, but I don’t have any skills that are particularly in demand.

24. I was thinking of moving to Canada. I wonder how my life would change if I could actually address my circulation problems with something resembling medical care. Heck the TV industry is already in Vancouver, anyway. And we all know there’s no reality unless it’s on TV.