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I am so sick of the US health care system.  Sometimes I wonder if less availability would be better - maybe the SYSTEM as a unit would function better.

Before getting to my most recent 'episode,' here's some historical anecdote just to set the stage.  Several years ago, while at work, I got lightheaded, felt faint and very pale.  With a history of heart issues from when I was younger, I figgered it best to get checked out.  So, I went to my primary care doctor, who ran an EKG.  He saw something there that warranted sending me over to a cardiologist ASAP.  They ran some tests and found nothing of immediate consequence.

Insurance did not cover it since I did not go to the emergency room.  W-T-F??

Two weeks ago, I went to the ER for something.  But, I learned that the Co-Pay for an ER visit is like 9x a regular office visit.  This is to discourage unwarranted visits to the ER. I"ve never been to the ER for anything that was not a genuine emergency, but I am 'punished' alongside those that do.  Yet a couple of years ago, my insurance did not even cover a couple thousand in tests because I did not go to the ER.

Again.  W-T-F??

So, now I am scheduled for outpatient surgery for next week in regard to the thing I went to the ER.  Now, the hospital tells me that I have to pay a deposit, to cover anything my insurance does not cover.  WHAT????  I told them I was not paying a deposit, and they said "okay, that's fine, too."  What???  Do they need it, or don't they?  Jeez.

Why even bother having insurance?  I hate the insurance system and the mindset it creates.  To me, it is similar to the withholding system on taxes.  If you make people pay AT THE TIME a service is rendered, they will know the cost.  Otherwise, it creates too much hidden opportunity for what I feel compelled to call corruption.

Thanks for the rant.  Back to Bad Movies....

The health care system in this country is a joke.  It's not there to help people, just there for the insurance companies to make a boatload of cash. 

That's all I'm going to say on that subject.  If I were to say more, then I'm sure it would spawn some sort of argument with those that feel the companies should get rich while not helping those that are genuinely sick.

Ulthar, best of luck on the surgery.  We'll be thinking of you.

Boy, this thread sure is going to get ugly the first time someone speaks in favor or socialized healthcare. 

So f**k it.

A European-style socialized healthcare system would fix everything.  EVERYTHING.  Right now, the healthcare industry exists as a business model to make money.  They have a bottom line to consider and while I ordinarily can't fault a business for considering profits and investors, this time around they're making money on the backs of people who desperately need healthcare and are paying out the nose for it if they can afford it at all.

One of the main arguments against social medicine is that it's more government, more beuracracy and longer waits since there's a standardized system in place and a priority queue but if you had to wait a little longer to get the help that you're guaranteed wouldn't it be worth it?

Everyone benefits.  We pay a little more in taxes, everyone gets the help that they need despite their social class and the quality of life in the United States rises.  There's a positive social impact there that extends beyond doctors offices and hospitals.

Am I dreaming?  In spite of healtcare being a hot button issue in the current presidential race, I think I am but I can dream.

So bring on the criticism.

That just seems to be such a stupid idea.  Who would want to pay a slight amount in taxes and get free healthcare?  I can't begin to imagine what kind of idiot would be for such a thing.

Karma.

I remember at the start of my career in computers (this was 1979), the company I worked for had great insurance. If you were single you paid no premium and they covered 100% or everything. The only time you really had to pay anything out of pocket was when your treatment for something reached $10,000, you had to pay the next thousand and after that it was unlimited. They also had a stipulation about if a service cost above what was reasonable and customary, you would have pay the difference.

They gave us these big envelopes with a form on the flap. You tore the form off, filled it out, threw in your receipts (including drugs), mailed it and then got a check in couple of  weeks.

When I got married in 1981 I had to start paying $4.80 a week to cover my dependents, no matter how many there were. Everything was paid in full for our two kids being born. 

Things changed in the late 80's when HMOs and PPOs started to appear.  Basically what this did was transfer the money from the doctors and hospitals into the pockets of the insurance companies.  There in lies the problem, the insurance lobby.

Nothing is going to change as long as interests with deep pockets control our elected officials.  Take the medicare drug program, this wasn't written to help people on Medicare, it was put in to effect to keep the drug companies from having to negotiate drug prices with the Federal Government.


We seriously need to address this whole issue, but it's not likely to happen with politics the way they are in this country.

We put government is charge of our schools now we are falling behind most of the western world in education and continuing to fall. If you put them in charge of health care what do you think will happen?

Just wondering ...

I believe (as a doctor who works in a non-profit HMO) that our system will inevitably take on the characteristics of socialized medicine, whether we call it that or not at the time.

And that is a good thing.  But it won't happen yet...   the shields are only down to 25%, and we don't as a rule fix things until collapse is imminent, and we aren't there yet.

Before anyone swallows the Sicko claims hook, line, and sinker... Ever asked a Canadian what they think of their healthcare system?

'T'ain't the promised land.

I've seen private insurance in action.  I've seen the government in action.  And if you think that private for-profit bureaucracies operating in a competitive marketplace are bad, just imagine what mandated and entitled government bureaus would be like.  It's be like getting your healthcare from the IRS.  Or the DMV.

For the federal government to be able to administer a healthcare system even as efficiently as our hobbled private-insurer morass, there would need to be a reinvention of government structure and culture that would dwarf the switchover to a public healthcare system.

I'm Canadian.  My Dad was a doctor.  Socialized medicine is not all you seem to think it is.  The grass may look greener, but you really should be checking it for spraypaint before you buy.

The wait times are killing people, for one thing.  The rest...well, what  you 'need' and what the system defines as a 'need' may not be the same thing.  My relatives in England have said it has been even worse over there for a long long time.

Bottom line: it still runs on a 'business' model.   Has to.  Every part of it is subject to drastic cuts and redefinitions in order to make it look good to the 'shareholders' - on paper.  As a result, many of us do not have the same access to care and facilities. In my community, the ambulance service covers such a large area that it cannot possibly respond to such things as heart attacks within the optimum time.  Not good with an ageing population.  And our ER (we DO have a hospital - of sorts; just barely) shunts just about everything to the city 45 minutes away (where the waits are regularly over six hours, often eight or twelve - been there with a sick child myself).  We have too few doctors - cannot pay them decently - so many people do not have a family doctor at all - my own family went without one for several years, and we have kids.

It does cover most essentials; if you can live with your condition and/or survive the wait for tests, diagnosis and treatment, I suppose that it 'works'.

Oy.  This kind of debate is too much to type (done it before) -- I guess the short form of it is that I don't wish for the US to take on a Canadian system or a British system.     I do think, though, that the current system is too all-or-nothing, and that something more in the middle is in the aggregate going to be better for most people.

I'll see if I can give an example.  Okay.  This is one facet of a small thing, but the principle is the thing.  Where I work, like in many systems, there is a formulary (a list of preferred meds).  There are financial penalties for not using meds on the formulary -- costs more to buy if it isn't on the formulary.      Our formulary is made up by a committee of docs, pharmacists, and some members of the cooperative, and each med on the list is weighed, based upon the evidence that it actually leads to better outcomes for patients, how safe it is, and yes how much it costs. 

So when someone comes to me with depression and she says that her friend does so well on Cymbalta, and she wants to take it too, we talk about what she has tried.  Turns out she hasn't taken anything for depression -- so for her, there's economic incentive to start her on Prozac or Celexa or perhaps sertraline (generic Zoloft) -- actually, generics of all three.  The randomized, placebo-controlled trials show similar efficacy between all these meds for the typical depressed person, so why spend 77 times more money per dose on brand-name Zoloft?  It's unnecessary, and wasteful.           If the patient tries several meds and fails them, yes, we might eventually move up to Effexor or a med like that (more expensive) but that isn't first-line.     If it takes several courses of medication, yeah, that's inconveniencing and has its own problems... but in the aggregate, I get to effectively treat a lot more depressed people as a consequence, and most people do better.       These decisions, as I said, are based on safety, efficacy and cost.

What about at a random clinic here in town?  That same patient might come in, and the doctor there has taken in some drug rep propaganda recently (no drug reps allowed in our clinic, by the way -- haven't seen one in three years, except at conferences, when I walk past them without pausing) and the patient ends up with some sample boxes of Cymbalta.  She does well on it, and wants to continue it.  Doc writes a prescription,  and the med is either   A)  not covered, and she shells out hundreds a month to pay for her med, when probably $10 of generic fluoxetine would have done as well, or B) it's covered, and EVERYONE pays more than necessary for the treatment of her uncomplicated depression.  (or C:  Doesn't take anything, gets sicker, loses relationships, starts drinking or using drugs, loses job, attempts suicide, is hospitalized... ... ...)

That's one facet of a greater philosophical approach to the problems of cost and risk/benefit analysis in healthcare decisions.  The cooperative I work in is  and has been on the leading edge of doing the right thing, for years.  I'm proud to work here.   If I could force every practice in town to make decisions the way we do, would I?   Yes, because we are trying to do the best evidence-based medicine for patients, with the lowest costs we can manage.    When I said that I hope our system (in the US) becomes more socialized-like, I was meaning more specifically, more like how some (non-profit) managed care works.  I apologize for speaking unclearly and in sound-bites.

Rebecca, I'm sorry to hear that you didn't have a family doctor for a while.   I hope that you've got better healthcare now -- there are quite a few people in the US who don't have doctors, either, nor any hope of being able to afford insurance (when the rates go up in double digit percentages each year, for several years in a row!)   If you could command the Canadian system to change, which changes would you make to improve it?

100% agree.  Therein lies the problem - the INSURANCE system.

I remember the pre-HMO days.  I also remember how HMO's were 'forced' on everybody as The One True, Right Way (tm).

The insurance industry operates on second derivative growth. The growth must grow.  I personally do NOT think any form of socialized medicine as the solution.    Like Newt said, you just trading one ill informed power for another.

Zap, the decision of which med to use for a given patient should be YOURS as her doctor.  You should not have to base that on some list a COMMITTEE decided was statistically best.  Humans are not averages.  Now, you can certainly use such a list as a guideline, but that should be as far as it goes.

My wife (also a doc) complains about these lists all the time.  You see, her problem is that in peds, virtually NOTHING is 'approved' for use on children because the clinical trials cannot be done because people don't want to use THEIR child in a trial.  So, the FDA says "no, it's not approved."  That does not mean it is not a good med, it simply means no one had paid for, and received FDA approval.  She fights this all the time, and now with the OTC cold meds, it's becoming a big deal.

Bottom line is that WAY WAY too much power is in the hands of the insurance companies.  And they do not have your interest or mine in mind.

I don't really have a good opinion on what to do about our s**tty health care system but I can say that I sure am having problems getting the insurance to cover the most basic things for my child, even when she has both parents with supposedly good health insurance.  This is all a pretty new experience for me because I haven't been to a doctor in about 20 years and don't even have a personal family doctor of my own -never needed one.

All I know is that I don't really want nationalized health care but it really p**ses me off when local hospitals over charge (like in the case of an 8$ q-tip).  They need to police themselves before god-forbid the government steps in.  I guess there just needs to be some kinda balance/something to keep things in check.

But at the same time, I don't think a child's health should be a factor in what's profitable and what's not.  Bah I don't know what I'm talkin about.  Damn ideals anyway.  I guess there's just no silver bullet on the mess we call health care.

Ulthar,

I am not forced to prescribe, or not to prescribe, anything.  But in terms of what it costs, there are direct and real implications in the choice.  In our formulary, the choices are based on what works best and safest, and often the new "me too" drugs (ie new twists on old molecules) are not better, just more expensive (and on-patent).  Their willy-nilly use ought to be discouraged in the absence of clear evidence of benefit for their cost.

I would never work for anyone who tried to tell me what I can and can't prescribe. 

If a patient has tried four antidepressants, for example, and hasn't done well on any of them, I could order venlafaxine (an expensive but effective antidepressant) and have it covered as a formulary med.     But if the patient has never tried anything and insists on venlafaxine, I can still order it -- I can prescribe anything I want -- but what the patient's insurance will and won't cover is and remains a separate issue.

In our system, though, we try to align what the insurance will and won't cover with what makes sense to cover first, or not.

Also, let me inject this into the thread:  not all HMOs are the same, and not all HMOs deserve their connotation.   I have worked inside and outside of HMOs, and have some experiential basis for this opinion.

I agree that the insurance lobby, and Big Pharma, are real and present dangers to all our health.

I've got Southern Health HMO through my employer.

I haven't had too many issues with them.  I looked at my card and I have to pay 150 dollars for an emergency room visit but I don't have to pay extra to go to my doctor after hours or on the weekends which is nice.

Urgent care is only a 250 dollar co-pay for no matter how long the stay is according to my paperwork.

But we all know how they can "change their mind" about stuff despite what's in print.

I have CheezeFlixz HMO I have coverage for really major stuff like a brain transplant, but the day to day sniffles and boo-boo I just pay it.

Regular coverage for me would be as a self employed person nearly $800 a month ($9600 a year), and I haven't spent $800 on health care in the last 20 years.

I think I may have mistated my position a little bit.  I realize that you can prescribe whatever you what, but as you state here, how/what is covered is the issue.  In effect, the insurance companies ARE 'telling' you what to prescribe in that you wish to do right by your patient's wallet.

My opinion is: the insurance companies should have NO SAY whatsoever in what is covered.  If you are a qualified, duly accredited physician, they should defer to your judgement.  ESPECIALLY in the insurance programs with 'approved' physician (like most HMO's, right?).

My rant that started this thread was precisely about the insurance companies.  How my 'cardiac' event, though not serious, was not covered due to what amounts to my going straight to a specialist rather than via the ER yet how the ER copay is 9 times that of a regular office visit to discourage ER trips!!!

My wife has cases of drugs that the generic is not covered, but the trademarked is, even though it costs 20x as much.  Worse, there is a particular drug, that they use VERY commonly, that they don't get reimbursed for, so they have to send the patient to the hospital to get the shot.  This costs the insurance company (medicaide in this case) like 10x as much as if they just reminbursed the private practioner to give it directly, but they won't do that because they are "afraid" the private physicians will overuse the drug and therefore run the cost up.

Even though they ONLY use it when it is MEDICALLY INDICATED!!!!!!

All you guys hoping for socialized medicine, latch onto a private practice whose primary patient base is medicaide and you will see what government provided cost coverage will do.  It's a mess.  And, it ultimately does not help those that NEED the care, at least not efficiently.

My solution:  make people PAY for health care (ie, most people, those of us with jobs), or at least their own insurance - get away from the 'health insurance benefit' provided by employers.  As long as the costs are "hidden," people don't know where the cost abuses are.  Federalizing the system only hides the abuses more.  At least that's my read, based on peripherally dealing with Medicaide issues for several years.

Fine in principle, except for one little sticking point:  Sick people.

The reason that group health insurance works (even as poorly as it does) is that it allows costs to be spread.  You work in a company with ten young fit single guys, and one diabetic depressive who has to have pre-cancerous polyps two years?  The costs incurred by the one are carried in large part by the other ten (and also by other clients of the insurer).

Those ten guys could easily get their own individual insurance policies.  But the one with health problems?  Ain't NO way.  Just to cover their costs, the insurance company would have to charge the sick one a premium of thousands of dollars each month.  So they simply won't take that person on as a client.  That increases the number of uninsured, and targets those who are ill -- who need health coverage more.

There are a few states where the legislatures, in their infinite wisdom, have mandated that insurers offer individual coverage to anybody who applies.  The insurers have responded by jacking their individual coverage premium to $30,000/year so that NO ONE will apply.

That's a big part of the problem: the INSURANCE company can charge premiums based on pay-out.  It's nothing more than legalized gambling, but with a garantee that you won't lose.

When they take my premium, they are gambling that I will pay in more than they have to pay out.  That's our tacit agreement.  Where the system goes bonkers is that AFTER they "lose" their bet, they get to charge me back for it.

What is insane is that we pretty much HAVE to have insurance.  If I chose not to, getting served is very problematic.

There are some doctors that are refusing to give care via insurance.  It's cash on the barrel-head.  And you know what?  The cost of providing care is MUCH MUCH LOWER.

Your arguement is premised on the notion that we ALL HAVE INSURANCE, and that we MUST have insurance.  I'm suggesting we break that premise, and go back to a system where one could CHOOSE to have insurance, and of course, requisite for 'my plan' to function properly, the insurance industry does NOT get to set the rules (as they are now).

Take a look at what medical care costs these days; for instance, hospital charges on the average no-problem childbirth are somewhere between $3000-5000.  If you want to pay that kind of money on your own, go for it.

What do you think is driving up those costs?

Many, many things.  One of them is new technology; baby-birthing didn't used to cost so much because the only equipment available was clean towels and some boiled water.  Same with so much of modern medical care: It's far better than it used to be, but better costs money.

One other is malpractice liability.  Malpractice insurance costs a buttload (yes, that's a technical term) because of the John Edwardses of the world who feel that every bad happenstance in the world should be somebody's fault, provided they get 40% of the damages.

And another, closely related, is pre-emptive or CYA care.  Doctors often order a full battery of tests on every hangnail not because they feel that that's what is reasonable for treatment, but to forestall a ruinous malpractice suit on the .001% chance that the patient has Galloping Hooperlungster Disease, and that a smooth John Edwards type may be able to rally a know-nothing jury into awarding umpteen gazillion dollars to assuage pain and suffering.

There are other reasons; like most systemic problems in the modern world, there's no one cause, and thus no one magic bullet that will cure it.

What's particularly interesting about child birth is that giving birth at home/at a center with a midwife is almost exactly as safe (there are a few problems they can't take care of, but it evens out by a far lower risk of infections, etc, from not being in a hospital) and costs far, far less.

This is true; we had our second child at such a birthing center, and it was a much better experience for that than with any of our other three.  By the time #3 came along, the center was closed.  Why?  Liability issues.

What truly boggles my mind is the notion that someone ELSE should pay for ANY service I receive.

All the reasons you mentioned for the rising cost of healthcare do play a part - I agree.  I also agree that it is a large, complex system with multifaceted problems.

But you did not mention insurance explicitly, though you did mentioned a corollary cause - law suits.  These are related, perhaps in subtle ways, but the malpractice lawyers and insurance lawyers are closely allied (morally, if not directly).  Both are after something other than the best service to the sick.  Also wrapped up within the same umbrella is the cost of patents for meds, which is a completely broken system in itself, and I alluded to some of those issues in an earlier post.

The bottom line is that the true value of the service is now divorced from the cost.   We are all paying for various abuses - whether it is the abuse of a patient seeking upper end care for a runny nose or abuse in the courtroom or abuse in the insurance companies dictating how care is delivered (to maintain their profits, not the best interest of patients), it is all one. 

I stick by my basic premise: if you hide the cost from the consumer, the abusers get free reign.  I am coming at this from a much broader pespective than I think it seems at first reading of my earlier comments.  The insurance based system in which we currently find ourselves mired is a part of the problem - a big part, I contend.

But you do that every day, don't you?  Most government services are paid for by taxes which, in large part, you didn't pay (unless you're a lot wealthier than I assume); many commercial endeavors gear their business model toward aggregate profit, not individualized bills (remember, movie theatres are losing money on you every time you see a film without buying something at the snack bar).  That's one of the premises of civilization:  Pooling of resources for the common good -- from each according to his ability, to each according to his needs.  I'm not claiming that private insurance companies are the best (or even a good) example of this principle in practice, merely that the principle itself is nothing to decry.



I will agree that the current "health insurance" system isn't truly insurance, in the form seen in house insurance or life insurance or car insurance... it's a pooled health services payment program.

Ulthar, I do not mean this antagonistically.  I'm just asking you to flesh out your thoughts with a specific example.

Let's assume you are fifty, you have diabetes with end-stage kidney disease, neuropathy, foot ulcers, and some coronary disease. 
You have been diabetic since you were six.  You have taken the best care of yourself, your whole life, that you could.  You have never rebelled against taking insulin, you have always done what you could.  It wasn't perfect, but you weren't stupid about things. 

So you had your first heart attack at age 46, and your kidney disease is getting worse.  You are certainly going to need dialysis within one to two years, despite best treatment.  You work, and still are able to, but you make, let's say, fifty thousand a year, and you live alone.  No relatives to help you, and some retirement money but that's it. 

Let us not assume that you are at any point crippled from working by a cardiac or infectious event, but simply that you require hemodialysis to survive.

Let us also assume that there's no insurance, and that you are going to pay for it all yourself.  Let us also assume that you have managed to save up some modest amount in a self-made medical savings account.  Let's say, fifty grand?  I don't know.  It doesn't matter greatly.  A hundred grand.

How are you going to afford this?   Okay, you spend some of your savings.  Not sure how much dialysis costs per week, but it's not chump chnage.

Okay.  Fast foward the scenario six years.  You are having an MI, and you are being wheeled to the cath lab, which you direly need.  You are found to have five-vessel coronary disease, and you are told you need CABG.  You won't work for weeks.

How are you going to afford this?  Let's even assume that you now have enough money to cover most of the bills you just incurred -- but that's all gone now.  You still need dialysis, and you're in the second half of your fifties.

What I'm saying is that it's one thing to criticize, and another thing to have a better idea.

TANSTAFL - There Ain't No Such Thing As A Free Lunch.

Any improvements I can think of - greater efficiency, better truly 'universal' access - would have to involve a huge amount of funding.  That's the rub: it is fine and dandy to say that everyone should be covered for everything and to have equal effective access - but it is going to cost us.  Canada is already one of the most taxed populations in the world.  The money to improve the delivery of our health care has to come from somewhere - and that somewhere will be our own pockets.  A fact that our more socialist politicians tend to (intentionally) gloss over.  They say, "Make the Rich pay" - implying that the billionaires should be taxed at a rate that will carry the costs for all the average Joes and their families - but they neglect to give their definition of "rich", which is anyone making more than minimum wage.  That's US.

In recent years, our health care system has undergone drastic cuts and closures - for lack of funds, in the name of increased efficiency.  We do not have enough nurses, doctors, EMT's, technicians...and we are closing hospitals and centralizing services.  This does NOT improve delivery/access in a country with a small population and wide spaces!

You can have all the social safety nets you want - as long as you pay for them.  And we are paying for what we get.

It broke my Dad's heart back in the '70's when our Provincial Health Plan got rolling: he was a true "country doctor" and when bureaucrats started telling him how much time to spend with each patient (he took too long and saw too few per day), how much each service was worth (he delivered a LOT of babies and was incensed that since a c-section paid $10 more than a vaginal delivery, many doc's were opting for more sections for the money...AND our veterinarian got 3X as much for the same procedure on a cow!  The joke at the time being, "But Doctor, these are valuable animals!"),  and so on.  He called it "assembly-line medicine" and felt he could not do right by his patients under such conditions.   It is worse now.

As for "from each according to his ability, to each according to his needs..." last I knew, that was a premise of Marxist Communism, not civilization at large.  It assumes "an abundance of goods and services" produced and controlled under a communist system.  Canada may be considered fairly socialist in its general outlook, but we have not yet achieved an "abundance" of anything, let alone health care services, adequate for the entire population (again: to have equal effective access) and simply awaiting distribution.  That takes money (as converted goods?)  and a great deal of it: another "abundance" we do not have individually or to share "for the common good".

Look at the "Canadian system" as being the 'economy' model and you won't be far off. Like democracy itself, it is far from perfect, but it is the best we have, given current conditions.

You're right, the slogan is from Marx, but I think it's true outside the ideas of Marxist communism, which was a top-down enforcement of ideas hinging on class struggle.  (Believe me, I'm no fan of communism of any flavor.)  In a successful and equitable society, the citizenry buys into that idea for the common good.

Which, I suppose, leads me into admitting the problem here:  That too many people are weasels, trying to chisel the system -- ANY system.  No form of health insurance, tax equity, or other social mechanism will work well unless individuals grasp "enlightened self-interest," i.e., that what is good for the whole is also ultimately good for the individual.  When individuals are motivated by greed, no system works; when individuals are motivated by brotherly love and unselfishness, any system works.

I agree with what you say about removing barriers between what we buy and how much it actually costs.  I think there's a real value to a person coming in and demanding an MRI for his knee that he injured yesterday, after being told by a physician that it's not at this point an indicated test, and then being told how much it actually costs.       But how do you pass on the cost in some systematic way without certain examples being utterly devastating to people?      Perhaps there's no solution.  But you are not actually posing a realistic solution, I think.

I might also point out that no matter the agency of it, the fact is that no matter to whom I prescribe anything, I must consider how and if the person will pay for it.

When I worked for a free clinic, I had to elaborately consider the choices of antibiotics and other meds against a given patient's ability to actually obtain the med.   Doesn't do a lot of good to ask someone to take a med when they can't actually buy it, does it? 

Working for an HMO, now, I know that the common and actually useful drugs ARE affordable to everyone I see, which is admittedly a selected poplulation (the insured).  But within that framework, I am more likely to successfully treat patients because they will get what I prescribe.

Your knee-jerk reaction to formulary logic is an unrealistic one.  Within any health care system, unless resources are limitless, one is of necessity going to make certain choices, force certain emphases if need be, to serve the greatest number.  To do otherwise is irrational and wasteful.  You speak of an insurance company as though it were a separate entity looking down on me and pulling my strings.  It isn't.  The cooperative for which I work is run and lead by physicians, and the kinds of choices we make in, for example, formulary is made by us, not by an outside agency.  That is not true everywhere, granted, but I think you misapprehend my argument here.

An element that we haven't touched on yet is the influence that pharmaceutical companies have on "accredited, duly qualified physicians," and the effects these companies can have on the spending patterns of health organizations.  Certainly physicians are not incorruptible.  My point is that there are many other forces besides insurance companies that influence physician behavior, and I think that the insurance factor is one of the more easily measurable, on-the-table and potentially changeable ones. 

Which drug are you talking about (the generic not covered, the brand-name covered)?

Let me be clear.  I am not opposed to insurance - as an OPTION.  I am opposed to the current system that has the following features with which I disagree:

(1) Pretty much have to have it; most doctors/hospitals won't look at you twice if you say "I want to pay cash."  The whole system is set up around insurance, so I don't really have a choice in the matter - well, not without HUGE, EXTREME inconveniences.

(2) Second derivative growth of the insurance companies; they cannot lose - they won't lose.  If they make a bet with me that I won't get sick, then I do, they lose the bet. But they then get to back-charge me for that in the form of higher premiums.  Or worse; they make that money back by increasing the premiums of others, sick or healthy.

(3) Insurance companies have WAY too much 'say' in the way the health care industry is regulated.  So far as I know, there is no Hypocratic Oath taken by Insurance Executives.  They are a business with the sole raison d'etre being to make money - to maximize profit.  Fair enough, but when the decisions they make to do so impact lives in a negative way, I find THAT problematic.

Someone (Nate, I think) above mentioned the comparison to car/home insurance.  You have a choice at what level of coverage you want, and you negotiate the value of that coverage against the premium it will cost.  If I have full coverage on my car, the Ins. Co is gambling that I won't wreck or get wrecked.  If the car is then totaled, according to the terms of my policy, they may have to pay out. 

They cannot say, "oh but you wrecked on a gravel road - we don't cover that" or "you were not using Goodyear tires, we only cover Goodyears."  Nor can they TELL me which mechanic to go to.  Futher, the pay-out is dictated by 'fair market value' of my car - NOT BY THEM.

In health care, the situation is completely different.  Much of the cost of things is determined by the insurance companies.  And, they DO influence behaviors (of both docs and patients) by what/how they pay.  To wit, my experience above with not getting coverage when I went straight to a specialist rather than the ER even though my co-pay is structure to discourage me from going to the ER.

So, my point is that I should have a (reasonable) choice in whether or not carry health insurance.  If I choose to gamble that I will remain healthy, then I get sick, the bill is on me and me alone.  If after getting sick with a chronic condition, and I try to get insurance then, I probably CAN but at a MUCH higher premium than if I had before.  That's fair, imo.

What I don't like is how it has become somehow expected or "normal" for health insurance to be the responsibiilty of the employer (of course, be self employed, this does not help me).  People complain about declining job markets, downsizing and the like, but often fail to realize just how much it costs someone to employ another.  Take base salary, add 14% for FICA, and another 20% or so for 'expected' benefits packages such as medical coverage.  To pay someone $35,000 per year, I would go about $55,000 out of pocket.  This is just insane.

If you are a small biz unable to negotiate large 'group rates' on medical coverage, it can be pretty bad.  Sure, there have been some recent improvements, spear headed by such groups as the NFIB, that allow small timers to pool their 'companies' to negotiate group rates, but that IS fairly recent.

My problem is that I cannot affort to front an employee $35,000 per year, much less nearly $60,000.  If I hire someone, the money they earn my company would go to their salary - I don't have a pile of cash laying around just to hire someone.

And I kinda resent the notion that I am responsible for their health outside the workplace.   Workman's comp covers at-work, so I am talking about MY paying for my employee's health benefit that ONLY covers their non-work hours.  Break a leg skiing on the weekend is my responsibility how?  Gray area of course is coverage for commuting.

So, to wrap this up, your example presents someone who would benefit from insurance coverage.  The kind of policy I would choose to carry (and always opted for when I was younger, pre HMO days) was catastrophic coverage - for chronic illness, real emergencies and long stays in the hospital.  Regular doctor visits were mine out of pocket, and I was cool with that.


But I do have a better idea.  Get the POWER out of the hands of the insurance industry, make "HEALTH' part of "health care" again, let doctors and patients be responsible for the care given and received.  Making folks pay for "regular stuff" is part of that, in my OPINION.  I (via my premiums) should not be paying for Sally's visit to the ER just because she had a runny nose, and if given OTC meds by the doc it is paid for, versus going to Eckerd's herself she'd have to buy it.

You see, my objections are the abuses the current system fosters.  My objections do not cross the line where need is very clear.

Does this clarify?

I haven't had time to read this entire thread but I know that HILLERY CLINTON want to require that everyone have health care insurance and equates that ill logic with that everyone is required to have car insurance.

Ok
1. You don't have to have a car, thus insurance is optional based on your choice to have a car or not. You carry insurance not to protect you but the other drive as liability is the minimum coverage.

2. I'm sure most people would think twice about getting auto insurance if it cost you $600 or more a month. The average American can not afford to carry health insurance if they had to flip 100% of the bill. If I was to carry full health coverage on myself it would cost in excess of $10,000 a year. That is insane, I haven't spent that much on health care in my 44 years of life.

Health care in this country is out of control and with double digit increases in cost every year soon no one will be able to afford it. Many companies no long offer coverage, they can't afford it, the leading cause of bankruptcy is incurred medical cost. Many Doctor's with respect to Zap don't go into the medical field because they want to help people it's because they are nearly assured wealth. Ever met a poor Doctor? I haven't. Now I'm not saying that don't want to help people, just the money that comes with it is more attractive.

Anyway the health care industry is screwed up in the country and I don't think government is the answer, they rarely are. But something has to be done, just what it is I don't know.

We need health care people can afford.
Doctors not afraid of being sued.
Lawyer's not chasing ambulances.
And a public not looking for a reason to sue.

What happened to the country Doctor with the little black bag that would help someone out for affordable payment or perhaps a chicken or pie? What happen to human decency and compassion for your fellow man?

Ulthar, that was a very helpful reply.

Agree, that if some kind of national insurance option were made, it would have to allow a fair way to opt out.   Absolutely agree.  Require people to buy insurance?   No.

I am in favor of each person taking more responsibility for his/her own health, and thinking long-term about what the implications of each choice are.   But in practice I find it to be a personal challenge to balance respecting (and requiring!) each person's individual responsibility for his/her lot in life with having compassion for each person.

It's easy to be compassionate for people who are struck down..   The people who make choices that I can't understand are the ones that are much more personally challenging, to me.

What can we do to make our system better?   I'm curious to hear specifics from people.   My thoughts:

1.     Physicians must police themselves.  We need to stop taking gifts from drug peddlers (big pharma), and we need to quit kidding ourselves -- we are not immune to the sales pitches. 

2.     The primacy of the doctor-patient relationship must be honored and strengthened.  Doctors must center their focus anew on what is best for each patient, and must regain the public trust.   (I don't think we have lost the public trust, but I think it's clear that the trust has eroded to some degree.)    At the same time, doctors have to help make the difficult choices (the ones that involve caring for the most people in the best way possible, with the resources that we have which are finite).    Patients must find a way to strike a balance between being their own best advocates and consumers of information, without trying to become the doctor.

3.     Tort reform.

4.     Somehow (and someone who understands these things better should chime in) we need to curtail the health insurance lobby.

5.     As a race, we need to rise above our short-sightedness and grasp the concept of stewardship of our own bodies and our ecosystem, and of the dignity of our fellow human beings.