You’re Sick. I’m Not. Too Bad.

There’s a popular, partly true, some­times useful and very dan­gerous notion that we can control our health. Maybe even fend off cancer.

I like the idea that we can make smart choices, eat sen­sible amounts of whole foods and not the wrong foods, exercise, not smoke, maintain balance (whatever that means in 2010) and in doing so, be respon­sible for our health. Check, plus.

It’s an attractive concept, really, that we can determine our medical cir­cum­stances by informed deci­sions and a vital lifestyle. It appeals to the well — that we’re OK, on the other side, doing some­thing right.

There is order in the world. God exists. etc.

Very appealing. There’s utility in this outlook, besides. To the extent that we can influence our well-being and lessen the like­lihood of some dis­eases, of course we can!  and should adjust our lack-of-dieting, drinking, smoking, arms firing, boxing and whatever else dam­aging it is that we do to ourselves.

I’m all for people adjusting their behavior and knowing they’re accountable for the con­se­quences. And I’m not keen on a victim’s men­tality for those who are ill.

So far so good –

Last summer former Whole Foods CEO John Mackey offered an unsym­pa­thetic op-ed in The Wall Street Journal on the subject of health care reform. He pro­vides the “correct” i.e. unedited version in the CEO’s blog:

“Many pro­moters of health care reform believe that people have an intrinsic ethical right to health care… While all of us can empathize with those who are sick, how can we say that all people have any more of an intrinsic right to health care than they have an intrinsic right to food, clothing, owning their own homes, a car or a per­sonal computer? …

“Rather than increase gov­ern­mental spending and control, what we need to do is address the root causes of disease and poor health.  This begins with the real­ization that every American adult is respon­sible for their own health.  Unfortunately many of our health care problems are self-inflicted…

Now, here’s the rub. While all of us can empathize, not everyone does. And few cit­izens go to medical school. Some, une­d­u­cated or mis­in­formed, might sin­cerely believe that ill­nesses are deserved.

So let’s set some facts straight on real illness and would-be unin­surable people like me:

Most people who are sick — with leukemia, dia­betes, osteo­ge­nesis imper­fecta, heart disease, mul­tiple scle­rosis, sco­l­iosis, glycogen storage disease Type II, depression, Lou Gehrig’s disease, sickle cell anemia, rheumatoid arthritis or what have you — are not ill by choice. They didn’t make bad deci­sions or do any­thing worse, on average, than people who are healthy.

Rather, they became ill. Just like that.

The idea of an insurance pool is that when everyone in the com­munity par­tic­i­pates, whoever ends up with large medical expenses is covered, explained Jonathan Cohn. When con­tri­bu­tions come in from all, including those who are healthy, funds are suf­fi­cient to provide for the sick among us.

As things stand, the insurance industry divides us into likely prof­itable and unprof­itable seg­ments. “So you know if you’re one of the people born with dia­betes, you have cancer, you had an injury that requires lengthy reha­bil­i­tation, tough luck, you’re going to end up in that pool of unhealthy people,” Cohn said.

Insurance is no cure-all, to be sure. It won’t take away my cousin’s cancer or fix Bill Clinton’s heart. That would require research and better medicines.

Depriving insurance, or care, to those who need it most is incon­ceivable to a society as ours was intended. It’s uncivil.

Elaine Schattner MD is an  trained oncol­ogist, edu­cator and jour­nalist who writes about med­icine. She teaches at Weill Cornell Medical College.  You’ll find her blog, where this post first appeared, at Medicallessons.net

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41 replies »

  1. Good article!

    I believe that most of the cases that doctors see are cases that have to do with preventable root causes, such as heart disease, blood pressure, etc. However, there are a wide array of health problems that are not behavior-related.

    Overall, because most of the cases are preventable by patients, I think a major emphasis should be placed by doctors on preventable care, rather than just prescribing drugs and treatment repeatedly. I think that a lot of the cost incurred by the patient is due to not focusing on the root causes of illness. Clearly, the patient must take the advice and the initiative to live in a more healthy way as well.

    Mark Cohen

  2. Perhaps it’s an innate human desire to believe that we are all in control of our destinies, but I think there’s something peculiarly American about this. That’s one reason some were so strongly against Health Care Reform that would expand the number of the insured: You are responsible for your own health and if you got sick it’s your fault. You were fat, you ate the wrong things, you smoked… it was something you did to yourself so why should the rest of us help you out?

    It’s not just diseases that are sometimes (but not always) related to lifestyle, eg lung cancer or diabetes. I’ve heard people blame other people for any kind of cancer they’ve had, asking what did they do to themselves to cause the cancer, even when the etiology of cancers aren’t clear. Did you suppress your emotions? Causes cancer. Eat meat? Causes cancer. Sunbathe? Causes cancer. It has to be something you were doing to yourself.

    Of course this is a self defense mechanism: Whatever you did, I won’t and so I won’t get cancer. It’s magical thinking, we don’t know how most (practically all) cancers start. You are not in total control of your health. People who get cancer aren’t blameworthy, people who live 5 years after a diagnosis aren’t necessarily heroes and everyone dies sooner or later. Trying to divide up the world into those whose diseases are worthy of our help and those who aren’t is a fools errand, sure to cause more grief than it would prevent.

  3. not sure about this data Margalit, it says actual payment but if I have one claim out of 1,000 that is out of network and I get stuck paying full price is that where the 95th percentile comes from?
    The spread between low, average, and 95th percentile doesn’t make any sense.
    Thank you for the link though it is interesting. One other question I have is I think I recall reading that our imageing is of much higher quality then that a lot of other nations use. I hav also heard that extra quaility/detail has little to no value but that would drastically change the solution. If we are using the same machines and charging twice as much then we need to lower the cost to operate and obtain the machine then what we pay for each unit of production from the machine.
    If we are paying more for better machines that aren’t needed then we need to….well not sure, change tort law so we can get away with lower quality scans and change reimbursements based not only on the test done but what machine is used to disencentivse costly machines?

  4. Two comments I know to be true, the first is an absolute, and the second a fair generality, and if commenters can come down to this point in the blog to read this thread, I hope they will echo, or perhaps debate:
    1. The costs of health care are driven by all parties involved in the process, that being patients, physicians, insurers, pharma and medical device companies, state and federal agencies of oversight, other providers outside physicians, families and significant others of patients, and others who are minority in percentage but count in the end.
    2. Responsible and accountable physicians have not and will not ever collude with health insurance companies, but as a collective there were too many whores and cowards that allowed insurance to intrude and disrupt the physician-patient alliance. So, as a group, we have failed, but as a majority, no, we are invested in patients, not wallets first.
    So, vilify away. I think those who pay attention to the truth and facts will not buy into the adage of “hear the lies enough and they will become truth.”
    Good luck trying to sell that bridge!

  5. Determine MD To answer your question is, not really. Patients do have some responsibility. I guess you would say malpractice and defensive medicine is our responsibility that drives up cost.However, if we eliminated these excuses Im sure their will be other excuses. Look, your being sponged off from Medical Malpractice insurance and do you dictate premiums. No not at all. Insurance drives up premiums and tells you what to pay and how to protect yourself from Law suites by ordering a battery of tests. Each Health Insurer permits you to choose specific coding to maximize returns. Doctors not only push for groups of tests because quanity pays larger premiums than quality. Defensive medicine is secondary to profit.
    Doctors may find insurers as partners in their venture,but often times Doctors will not speak up if they disagree with insurers. They do not wish to bring attention to themselves among their peers. Little be known to most of their patients. Doctors can face real problems with health insurers which have strong connections with Medical Boards.
    These Insurers and Providers have the largest influences in reducing costs but it appears they do not agree.These are the people who set and agree to contracts,but the users are all at fault. You have got to be kidding! I know one way to drive down costs is to provide Free Market Competitive prices and get walmart CEO’s to drive down prices. Its not just doctors ,but providers a whole host of industrial related services. Mr. MD tell me HOW Medical Errors and Hospital Acquired infections are the patients fault for $12 billion dollars in additional costs. Maybe you are a fan of Nate.

  6. “When the Patient becomes a active participant in these contracts .Then and only then can you blame the costs of Health Care on them! Until then ,you will have to stop lying to yourselves as who is responsible. It rest soley between insurers and providers!”
    You have got to be kidding me!? All patients have nothing of responsibility or accountability to the role of escalating health care costs? This is why I continue to be astounded by the sheer audacity and cluelessness behind these attacks on providers. There has to be someone to lynched for the problems of our society, eh, Mr Lampman. Can’t attack 300 million people, so go after the fewer 700,000 physicians, or if you truly infer all providers irregardless of discipline/training, then I guess we’re talking about a couple of million or so?
    Are you a fan of Ms Mahar by the way?

  7. Your sick I’m not to bad. Your sick,can’t buy access to bad so sad. The GOP’s perception is if your sick and going to die. Die Quickly! This a throw away generation that implies and infers that once you have out lived your usefulness.You should be kicked to the curb and put down. Insurance is a market of death panels for self profit.A interfering force that has been designed to push self serving Greed and profit margins at the expense of their subscribers. Insurance aligns its self with contracts that promote their selves and exploits the poplulation. The same is true of Providers. What happens when the the targeted subscribers are without a seat of the table.The patient has become increasingly exploited to maximize profits.
    Some say that every incidence of Higher Costs is the fault of the patient. I disagree! The Patient has been excluded from partaking in the choices made by insurance and providers! Oh ,please explain to me why is it the Patients Fault for Hospital Acquired Infections and Medical Errors made by the institutions. Explain to the patient; that has been harmed,Why it is the insurance Companies that continue to pay for these infections and medical errors without a question. Why they do so is beyond me! Hospitial Acquired infections account for 90,000 deaths a year more than AIds and Traffic Accidents. However, Insurance still pays and has done NOTHING to reduce these preventable Infections. Oh ,Please;How sick it is to blame patients of Harm for rising Costs! Get off your lazy backsides and actively engage in cutting out Preventable Infections!
    Insurance has the ability to influence providers but choose to set on the side lines and gloat over their profits. It is a amoral behavior and that derides the core of Health Insurance.
    The term you get what you pay for is a clear misnomer. I can say sometimes but not all the time! I don’t think that it matters to insurance and providers if you get what you pay for. I guess it depends if they make you better or make you worse and/or just fail to rescue.
    When the Patient becomes a active participant in these contracts .Then and only then can you blame the costs of Health Care on them! Until then ,you will have to stop lying to yourselves as who is responsible. It rest soley between insurers and providers!

  8. Nate – The Health Affairs paper on the Swiss healthcare system last summer included comments about much higher prices paid here vs. there for just about everything. Also, Uwe Reinhardt at Princeton published a paper, also in Health Affairs in 2003, I believe, titled “It’s The Prices, Stupid.” I think you can access an abstract of the article through Google but a subscription to Health Affairs is needed to read the whole thing, unfortunately. Our utilization of major procedures is not that different than in other countries. Some other countries actually consume more drugs than we do. Our utilization is higher in areas like diagnostic imaging and while hospital lengths of stay are longer in other countries than in the U.S., on average, a lot more happens to the patient in a U.S. hospital for each day he/she is there.

  9. “the answer is that every dollar we spend here is buying less than a comparable dollar buys in Switzerland, for example.”
    Do you have anything to support this? The studies I have seen said our per unit cost is not higher then most other countries. Rx is the big exception here on Brand name drugs, Genric we are substantially cheaper.
    Our utilization/consumption on the other hand blows them away.

  10. “No Peter that is how Obama saves his friends and contributors money by giving them exemptions so they can cap it at $50,000 or less.”
    Nate, from this examination Republicans seem to be doing very well also. What right-wing-rant show are you getting your info from?
    But this is only a 1 year waiver.
    “Now that you know its your god Obama doing what do you think of it?”
    I no longer support Obama after he caved in to Republicans on the Bush Tax cuts and threw in a reduction to the inheritance tax AND reduced payroll deductions as icing – he has shown no commitment to principle, other than Republican principles. Prior I lost much support of Democrats (who I have characterized as cowards) since they failed to cut health costs in this reform.

  11. Jumping in a bit late, but I think Barry has hit the nail on the head.
    We keep arguing about HOW to pay for health care, but we need to discuss HOW MUCH we pay for health care. You can slice and dice various pools and coverages, but those are questions of equitable distribution of resources, or lack thereof. The big question in my mind is what do our resources buy us, and the answer is that every dollar we spend here is buying less than a comparable dollar buys in Switzerland, for example.
    We need figure out why and fix that first. Until we do that, all the insurance reform stuff is not going to help much, and neither will the increasingly popular efforts to “reduce utilization”.

  12. “but obviously you’d pay more for annual $50k max over unlimited”
    Actually Peter a plan with unlimited max is considerably more expensive then one with a $50,000 limit, obviously.
    You said the people Obama has given exceptions to are still paying into the pool, but they are paying into it at such a minimial level they are not contributing like you claim everyone should.
    ” Is that how you save your clients money Nate”
    No Peter that is how Obama saves his friends and contributors money by giving them exemptions so they can cap it at $50,000 or less. Now that you know its your god Obama doing what do you think of it?

  13. “Peter paying into the pool for a plan with a $50,000 annual max is the same as paying into a pool for a plan with an unlimited lifetime max?”
    Don’t know what you’re referring to, but obviously you’d pay more for annual $50k max over unlimited – what’s your point? Is that how you save your clients money Nate, giving their employees a $50k annual max? Coupled with HDHP, no wonder you’re able to have lower cost plans.

  14. shocking Steve has no idea what he is talking about, who would have ever guessed.
    ” No one really knows the number of recissions. It is very hard to get much data from private insurance companies.”
    Actually its very easy to get, the state who regualtes the insurance company and grants their license to operate sends a letter to the CEO or compliance department and ask for the number then 2 weeks later they get an exact amount. Read any of the numerous articles out there on states investigating this matter and not once do they say they don’t know how many times it has happened.
    “but it has a frightening effect upon the whole system.”
    Actual recissions do not have a frightening effect, MSM and politicians blowing it into a much bigger deal then it really is and ignoring the cause of it has a frightening effect.
    ” In the US, we separate into pools by being healthy or unhealthy.”
    Lie and you can’t produce anything to back up this baseless claim.
    ” If you are unhealthy, you only get insurance through group plans.”
    More ignorance and lies. Unless you define unhealthy as the top percent of sick people individual insurance covers people who by any common sense measure would be classified unhealthy. In numerous states individual health plans can rate from .8 to 1.7, if .8 is a healty person then what is someone at 1.7?
    “This from a combination of higher administrative costs and underwriting (meaning they assess the health of your employees).”
    More stupidity, large group is 100% underewritten, so how does small group which has rates only partially medically undwriten at a disadvantage? Small group pays more mainly becuase it is guarantee issue so sick groups can buy coverage and have it subsidized by healthy groups. In the large group market companies are on their own to mitigate their liability. Thus large groups are usually more aggresive in controlling cost becuse there is no one their to pick up the bill if they don’t.
    “Every other first world country has resolved these problems”
    BS every other country in the world is also grappling with out of control cost and making changes to move more to a US system while the liberals in the US are rushing into a system the rest of the world has shown doesn’t work.

  15. I am tired of being overweight, I have started doing lot of exercises and controlling my diet, I don’t eat too much fat, taking calorie balance diet, but I just loose I Kg in a month, I am worried about my obesity. I am a migraine patient, too much exercise and dieting causes severe migraine. I need your medical advice to get rid of obesity.

  16. Many posters seem to believe that it is only personal behavior or bad luck that determines health. There is an intermediate problem of socioeconomic status. There are many studies on this topic (and, yes, adjusted for behavior). The fact is that the folks who post to this site — and certainly CEOs of big companies and Congresspeople — are better off because of their education and income.
    Come to think of it, so are most Whole Foods customers.

  17. 1) No one really knows the number of recissions. It is very hard to get much data from private insurance companies. Those who work for them have financial incentives to minimize the numbers. I suspect the number is pretty small, but it has a frightening effect upon the whole system.
    2) In the US, we separate into pools by being healthy or unhealthy. If you are unhealthy, you only get insurance through group plans. If you are sick, ad especially if you are also older but not yet Medicare age, you dont get insurance in the individual market.
    3) This carries over into small businesses. They generally pay about 18% more than larger companies. This from a combination of higher administrative costs and underwriting (meaning they assess the health of your employees).
    4) Every other first world country has resolved these problems by putting everyone into the same general system, yes they mostly work through private insurance companies, and requiring that everyone have health insurance. Only the US does not do this, and we have more expensive health care with a poor ROI in terms of quality.

  18. Peter paying into the pool for a plan with a $50,000 annual max is the same as paying into a pool for a plan with an unlimited lifetime max?

  19. old? that sir is out of line.
    From YOUR link;
    “20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.”
    Thats 4,000 people per year. That includes legitimate cancelations, or are you saying people should be allowed to lie on insurance applications for cheaper rates? How many questionable receissions where there? few dozen? How many people lied on their apps, 10s of thousands a year. You want to ignore the 10,000s of people lieing on their apps to prevent a dozen questionable recissions? And you wonder why insurance cost is so high.
    Liberals, I don’t know if you subscribe to this or not, already complain about the overhead of insurance, do you know what it would do to the cost of an individual policy if everything had to be verified upfront? Are you trying to price more people out of the market? The most efficient way to sell a policy is to assume the person isn’t lieing. Yes they very easily could eliminate the problem by doing health checks and in person applications but you just added $100 to the price, probalby in the form of an application fee that is not refundable. Does that sound like a logical solution?
    Just once I would like to hear ANY liberal that complains about recission address the problem of insurance fraud and how they suggest we resolve the problem.
    So rbar, you ancient gargoyle, instead of recission for people that lie on their application what do you suggest?

  20. “At least 733 companies, labor unions and states, covering more than 2.2 million members, have managed to get special exemptions”
    Give us all the info Nate. These are exemptions of plans that provide health insurance, not exemptions for NOT providing coverage.
    “Waivers only last for one year and are only available if the plan certifies that a waiver is necessary to prevent either a large increase in premiums or a significant decrease in access to coverage. In addition, enrollees must be informed that their plan does not meet the requirements of the Affordable Care Act. No other provision of the Affordable Care Act is affected by these waivers: they only apply to the annual limit policy.”

  21. Oh nate, you old troll, why do I even respond to your trolling posts? There are 300+ Million insured in the US? That doesn’t even work if you lump in medicare and medicaid (and rescission is a problem:
    these 20K rescissions was just done by a few companies, who knows what the actual rates are).
    But anyway, most people here are well aware of the connection of pool, pool size, health status and cost. But if an insurance company raises premiums because a small bussiness client has some sick employess/family members with cancer/injury etc., that just proves that this particular pool is too small to maintain itself/be a viable pool. That pool should be part of a larger pool (and getting extra funds from either healthy premium payors or taxpayers both fit the bill). And that’s how it works in the rest of the civilized world -the sick and needy get money from the rest. But never from Nate, or take it from his cold, dead hands.

  22. You know what I find both amazing and repugnant about much to these arguments to push this legislation forward? Per these advocates and defenders of PPACA, everyone in the country is equal, irregardless of their baseline health situation, and that is just a stupid, ungrounded premise! And that is where you fail in your agenda.
    Well, if this was utopia and fantasyland where everyone had an equal chance of long lasting life and opportunity, why stop with health care? Guarantee jobs, cars, homes, daily food sources, hell, guarantee absolute life, liberty, and the pursuit of unchallenged happiness! But, you can’t when the boundaries of reality and limits rear their ugly head into the picture, EH!?
    Why should I pay for someone else to access full health care options who smokes, eats irresponsibly, engages in reckless and dangerous behaviors in the community on a daily basis, and has no regard for others around him/her with attitudes and expectations? This is life, and in most societies, you make poor, ill conceived choices and plans, there should be consequences. It is called selection, it is called probable outcomes, it is called reality!
    And you know what I have learned about people who don’t stop at simply advocating for those who struggle and instead aggressively push for the full society to spend their time, money, and energy to save everyone? They are not truly, fully sincere and don’t act in a complete and invested effort while they scream and demand others to participate. And I know this of a sizeable majority of this group overzealously selling PPACA by what I hear and read not only here, but outside this site as well.
    Their comments and philosophy is really not based on reality, and I think it is genuinely insincere in the end, to dismiss the concerns raised by those who come to the debate acknowledging the strengths as much as possible detriments in the bill, which there are both, just because the bill is at all challenged. Come on, this is about the Democrats first, and, oh, if it works in the end, wow, that is wonderful it did work, not that this endpoint will happen!
    The fact alone that there is this dialogue to get back in the public option is just reinforcing my comments. Come on, unbiased and objective readers, who are most likely independents and moderates, listen to the rhetoric and manipulations by both ends of the extremes. Who do they represent? You, mainstream and middle America? Bah!!!
    Just watch the attacks of the usual suspects who will turn to primitive, empty defenses to vilify and demonize me. Someone who has worked in community care for over a decade.
    So, yeah, people should access insurance without preexisting conditions, children should be able to get care and it be paid for without much challenges, and there should be some basic equality for people to access providers. But, how can universal health care be paid for if it is for everyone, without sound limits, and why can’t people chose to opt out, albeit a risky choice?
    Face it, the mandate is setting a terrible precedent that those who want to control and manipulate America do not want you to realize and debate where it could proceed!
    By the way, I thought this was a good post!

  23. Dr. Schattner, no one can deny care except you, the doctor. The insurer does not deny care. It upholds the terms of contract regarding what it covered, and what gets paid, again, according to the contract.
    And if the client feels the contract is not upheld, there are internal and external reviews and recourse for them.
    What’s the recourse if you – and your colleagues – deny care?

  24. Mark and Lynn –
    In my comment, I tried to quantify what it would cost to replace COMMERCIAL INSURANCE plus cover the currently uninsured with some sort of tax and pegged the cost at 6.4% of GDP. I assume Medicare and Medicaid would be left intact. Those two programs combined cost between 6.5%-7.0% of GDP. Healthcare costs amounting to close to 2% of GDP are attributable to out-of-pocket payments. The rest include such categories as R&D, hospital construction, public health initiatives, and dental and vision care. The latter two, are usually covered by separate policies sometimes provided by employers or purchased individually and were not counted in my earlier comment. Altogether, it adds up to over 17% of GDP for healthcare in the U.S.
    I’ve also said before that if we were to adopt one of the European approaches, the Swiss system would probably be the best cultural fit for us. Switzerland, by the way, spends the second most in the world on healthcare as a percentage of GDP (about 12%). In Switzerland, people buy their own insurance policies and choose from among 84 insurers though the six largest control most of the market. There is no public option, even for the elderly. Insurers negotiate with providers as a group in each canton (there are 26 cantons in Switzerland) and all pay the same rates for a given service, test, procedure or drug within a canton. About 40% of the population qualifies for a subsidy but they need to spend at least 10% of their own income for health insurance before subsidies kick in. Some of the cost of operating hospitals is paid through general revenue which helps to hold down premiums. Also, a whopping 30% of healthcare costs are paid out-of-pocket. At the end of the day, about 35% of healthcare costs in Switzerland are covered by premiums that individuals pay themselves, another 35% covers the cost of subsidies plus a portion of hospital operating costs and, as mentioned, 30% is paid out-of-pocket.
    I suspect that if the Swiss had to pay U.S. prices for healthcare, especially hospital based care, drugs and devices, their costs would be close to 17% of GDP as well. Interestingly, when I was there this past summer, virtually everything cost significantly more than what it would cost in even our most expensive cities including NYC. Yet, somehow, healthcare is cheaper. Go figure.

  25. rbar if you have an unprofitable pool or if non profit a pool that does not meet underwriting guidelines what options do you have but to increase premiums? That’s like saying government shouldn’t raise taxes to cover Medicare cost, where do you want the money to come from?
    rescission was not a problem, it was a blown up story to gain sympathy and pass legislation. How many honest people had their policies rescisended? Few thousand? That is a rounding error on the 300 million+ insured. Compare that to the number of people caught commiting insurance fraud which is totally ignored. Why is it acceptable to let 100,000 steal insurance but oh my god don’t dare let 1,000 suffer for not accurtly completling their forms.
    “make “poor choices” the main argument against universal coverage based on the principal of solidarity ”
    Where was any argument against universal coverage made? I don’t remember even seeing the word unioversal coverage let alone typing it. Now I did correct a terrible misunderstanding of how pools work. Any time I correct someone’s factual errors I am automatically against their point? Assume much?
    rbar you don’t think UK has Universal coverage? They have more then one pool. I can think of a number of countries that have universal coverage with more then one pool. Thank you for another example of people running at the mouth with no idea what they are talking about.
    I think your also missing the meaning of solidarity, stiffing thy neighbor is not solidarity in the classical sense.
    ” Those are unnecessary, commercial entities that siphon needed funds from our health care system.”
    If you would brag about your economic ignorance in your bio we would understand the stance you take. Elaine apparently believes in healthcare fairies that magically facilitate payments, track records, and handle banking with no cost. Elaine exactly what system is it you wish to replicate that lacks insurance companies? Medicare and Medicaid uses them, every other country has them. Would love to hear about the system in your head that can do without them.
    “The insurance market as it works today basically slices and dices the population. It says, well you people with medical conditions, over here, and you people without them, over here”
    Please explain how Anthem with one individual policy pool in most states does this. It would be nice if there was some way to hold Liberals accountable when they say stupid things like this. Cohn is a moron who knows less about insurance then Ezra Klien. If he can’t even go to a states website or companys finacial filings and learn the basics of how pools work what value does anything he says have?
    “By the way Nate, “liberals” want everyone (paying) in the pool, young, old, sick, healthy.”
    Really Peter, hope your not wearing shoes;
    “At least 733 companies, labor unions and states, covering more than 2.2 million members, have managed to get special exemptions”
    but Peter said Liberals want everyone paying. Everyone but their closest 2.2 million friends and donars.

  26. Barry, establishing single-pay does not include establishing it with the present cost structure.
    “Is it really fair to confiscate 15%-16% of their income to pay for a benefit that most of them will make very little use of?”
    Is it fair to mandate they take the company’s heathcare plan? Is it really fair to “confiscate” FICA from them? You might say they at least will get Medicare and SS benefits, but at some point in their lives THEY will need medical care. That’s the thing about all insurance, only a small percentage gets to use it – that’s why they make profits. Excluding the young from contributions would only increase the cost to everyone else.

  27. Industrialized economies that also struggle with health care cost and quality issues have decided to finance their peoples care in some universal fashion, except the US. OECD nations accept that health is a public good/service from which all citizens benefit and all citizens share to finance. Some use a quasi-insurance model to allocate funds other don’t.
    Only in the US do we still struggle with health as a private good/service financed from 50% private and 50% public resources. It is this basic difference that pushes us into a fragmented dysfunctional health care system that is too expensive, denies access to millions, and provides questionable quality to the insured and the un or underinsured alike.
    A system that is neither fish nor fowl is no system at all. We finance k-12 education as a public good and higher ed as a private/public good. Why not do the same for health services? Basic care that is universal and supplemental services via supplemental private insurance?

  28. Barry,
    If we could cover the entire population for only 6.4% of GDP, it would be a bargain considering that we currently spend about 17% of GDP and don’t cover a lot of people. The 6.4% would also put us in the same league as France, Switzerland, Germany (… all other developed countries) who manage to cover all of the population for less than half what we spend.
    My daughters (in their 20s) who are healthy currently spend about 10% of their income on health insurance and care so they are not getting any bargain under the current system. They currently pay a FICA tax for Medicare which they will not use for many years. An additional tax which would replace their current health expenses would be fair.

  29. Peter and Elaine –
    “liberals” want everyone (paying) in the pool, young, old, sick, healthy.”
    The issue that those who advocate for a single pool financed by taxes to pay for health insurance don’t squarely address is the size of the tax that would be required to replace current employer provided health insurance coverage, individually purchased coverage, and coverage for the uninsured even assuming the Medicare and Medicaid programs remain in place.
    Approximately 160 million people currently have health insurance through an employer while another 18 million or so purchase individual coverage. To replace this coverage plus cover 50 million uninsured would cost between $800 billion to $1 trillion or between 5.7% and 7.1% of GDP. Split the difference and call it 6.4% of GDP. If we financed health insurance with a dedicated value added tax (VAT) that worked like those in most European countries, we would need a VAT rate of 16%. If we opted for the dedicated FICA tax model that finances Social Security plus Medicare Part A (hospital charges), it would likely require a rate of 15%-16% of wages.
    No matter how we financed it, it would be a horrible deal for young people who, at the population level use only about 14%-20% as much healthcare as those in the 55-64 age bracket. Young people just starting out are not making nearly as much money as their older counterparts. Is it really fair to confiscate 15%-16% of their income to pay for a benefit that most of them will make very little use of? People have different views on this but it’s a conundrum that needs to be addressed squarely and honestly.

  30. I would add that the title of this piece would have characterized our system better if it said;
    “I have subsidized healthcare. You don’t. Too bad.”

  31. “You seemed to have skipped the part where I pointed out their are not different pools for health and sick people, they are in the same pool based upon what they buy and when not their health.”
    Are they not separated in the same pool by risk rating? Works well with car insurance when you can clearly avoid risk by behavior and opt for a less expensive car to be able to drive, or tell your teenager to take the bus, but health care does not work that way. By the way Nate, “liberals” want everyone (paying) in the pool, young, old, sick, healthy.

  32. Thank you for your comments. Please note that the original version of this post, on Medical Lessons- http://bit.ly/dnbJlP, started with a quote from Jonathan Cohn) that was omitted here:
    “The insurance market as it works today basically slices and dices the population. It says, well you people with medical conditions, over here, and you people without them, over here…” (J Cohn, speaking on The Brian Lehrer Show, February 16, 2010)
    My concern is not with the well-being of insurance companies, about which I am unfortunately familiar. Those are unnecessary, commercial entities that siphon needed funds from our health care system. Rather, I’m focused on the needs of the community.
    About Wendell Potter’s work – I had the opportunity to hear him speak recently and am eager to read his book, which I agree relates to this discussion of the role and purpose of the insurance industry.
    As for guilt, well, I don’t think you’ll ever get that out of me.

  33. Elaine,
    I think it is very scary to be seriously sick and to add to it the guilt that you have brought it on yourself is just too much baggage. I think that much of the talk about health insurance is very biased- to me as a health care provider it makes good economic, ethical sense to cover all people. If we don’t cover people for health care, we all will still pay for it as a society, it just comes out of a different bucket and adds to all the misery that is already there.We cannot prevent all ill-health – to think that we can is just naive. I think we can cover all people for healthcare- if we have the intention.Of course, we will have to think about what care is justified- both ethically and economically.
    Thought provoking post.

  34. I am in favor universal coverage. But this post covers only one side of the story. We (in the US more than everywhere else) have to work hard on lifestyle changes. The growing type 2 diabetes disaster (and the ensuing renal failure, PAD, CAD, stroke disasters) has to be adressed by lifestlyle modifications.
    It’s telling that our apparent market libertarians such as Nate insist on government not interfering with food and lifestyle choices (for instance by modifying taxation and zoning laws) but OTOH make “poor choices” the main argument against universal coverage based on the principal of solidarity … and acting as if well documented problems such as rescission and steep rate increases for unprofitale pools/clients don’t exist. As a side note, I can recommend Wendell Potter’s book
    in that regard.

  35. Mark,
    What do you think happened to that person you no longer go out to eat with? If we have the community pool like she said all those people that are dishonest and take advantage of the sitution would now have a buffett of options. With the community pool there is no where to kick them out or no mechanism to make them socially responsible, your comment actually enforces my analogy.
    ” not their desire to be stuck with needles and prodded with strange instruments.”
    No one would ever go to the doctor to score some loratabs, oxy, zanayx or anything like that right?
    “that is, put all the sick (expensive) people together and charge the exorbitant rates and put the healthy people together and make lots of money off of their fear of getting sick.”
    You seemed to have skipped the part where I pointed out their are not different pools for health and sick people, they are in the same pool based upon what they buy and when not their health.
    Mark I read the post and it was her comment on a single pool that my entire responce was about. A single pool would not accomplish what they think it will nor would it work. Further I never said people are penalized for staying healthy. Can you name a public pool any where in the world where funds were sufficient to cover all submitted/desired care?

  36. Hi Nate,
    I’m sorry that you have friends who eat too much or leave before splitting the bill but this has only happened to me once and I don’t see this person any more. Perhaps you should get some new friends (and a new analogy).
    People don’t get sick just so they can use their insurance and the amount of medical care they “consume” is usually driven by doctors ordering tests and procedures, not their desire to be stuck with needles and prodded with strange instruments.
    I think you understand well how insurance pools work from the perspective of insurance companies… that is, put all the sick (expensive) people together and charge the exorbitant rates and put the healthy people together and make lots of money off of their fear of getting sick.
    However, I believe that the author, Elaine, was referring to the concept of one single pool where everyone participates (she actually says that if you read the post) and spreads out the risk for the small number of sick people among everyone. Before you protest that people are being penalized for staying healthy, please read Elaine’s post again… you may be smug and healthy now but you probably will get sick (through no fault of your own) some day. In that case, you should be happy that the healthy folks are keeping you from going bankrupt.

  37. “whoever ends up with large medical expenses is covered, explained Jonathan Cohn. When con¬tri¬bu¬tions come in from all, including those who are healthy, funds are suf¬fi¬cient to provide for the sick among us.”
    Your first problem Elaine is your quoting someone who doesn’t understand insurance and apparently has never heard of moral hazard. This is where liberal ideology always fails, yes on paper funds would be sufficient, in reality they never are. It’s like you people have never gone to a bar or dinner and tried to split a tab evenly. There are always people, knowing the tab is being split evenly, that will consume far more then they need or is equitable. Then there are always people that leave early before the check arrives, and finally people that wait till the check arrives to ask to borrow money, hard to give it back by that time, leaving everyone no choice but to cover them.
    While you appear to understand the concept of an insurance pool you don’t appear to have any understanding of the actual application and running of an insurance pool.
    “the insurance industry divides us into likely prof¬itable and unprof¬itable seg¬ments.”
    Again you and Cohn apparently lack any knowledge of how insurance pools work. I always find this frustrating that people can take an hour to write a post like this but can’t take 5 minutes to learn what they are talking about. You are divided into pools based upon the product you buy and when you buy it, not your health. I would love to see either of you explain or provide an example of the unhealthy pools outside state high risk pools, they don’t exist.
    If you want to discuss uncivil how do you rate taking to the internet to make things up and mislead people? In a society like ours, if your trying to steer national thinking shouldn’t you be honest with the public? Or with your politics is it win any cost necessary? If you need to lie to a few million people to gain support for your failed politics that is ok?
    I have a crazy idea you should consider along with Cohn, if you don’t understand insurance pools, whioch neither of you are even close, don’t go public writing about them.