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It seems to me that the problem with most “conservative” commentators on the Obama health care reforms and on the health care situation in general is that few of them have been victims of the current system. They have had good health insurance through their employers all their lives and think that anyone outside the system is a deadbeat or an illegal immigrant. Having experienced first hand the downside of the system I would like to make a few comments. I would note that the current insurance structure basically stinks. It denies insurance to those who actually need it unless they are employed by a company that offers that benefit (fewer and fewer do). Insurance companies exist to make money, not to make people healthy, and there is no money to be made in paying out for those who are sick.

My own experience with health insurance has been nearly always bad. I have been self-employed since leaving the government seventeen years ago and my health insurance has come through my wife’s employment. Being self-employed and not having any actual employees, health insurance companies will not let me buy into a group plan, meaning that any attempt by me to buy insurance directly would have cost roughly six times more than a group plan provided by an employer. My wife has lost her job twice and on each occasion we have only been able to continue insurance under COBRA by paying three times what it cost us when my wife was employed. My wife lost her job most recently last September and we began shopping around for insurance. My wife is in her mid fifties and I am in my early sixties and we have some health issues, though nothing serious, as I’m sure is true for most people our age. We were initially denied any insurance coverage but eventually were offered a health insurance policy, reluctantly, by Anthem at $3000 per month, which we could not even begin to consider. We finally opted for catastrophe insurance at $700 per month which offered basically no coverage unless we were to have a serious health problem, in which case the insurance would kick in after we had spent $6000 of our own money.

So we were in a situation where we had enough resources to pay for insurance but the health insurance industry was doing its best not to provide us with coverage because it assumed, correctly, that we might possibly cost more than we would be bringing in. I do not favor a national health system but I do believe that every citizen should be able to buy into a group insurance plan without the insurance companies denying benefits for health conditions and for employment status. There is something very wrong with the current system which, I think, can be fixed without nationalization by improving access to what already exists. For what it’s worth, I know of a fairly large number of people my age more-or-less who are in health insurance limbos very similar to ours. They have fallen in the huge crack between employer provided group health plans and medicare and are now finding themselves either with no insurance or insurance that covers nothing and still costs many hundreds of dollars per month. It really is an uncaring system that only concerns itself with the bottom line.

(Republished from The American Conservative by permission of author or representative)
• Category: Foreign Policy • Tags: Obamacare 
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  1. I’ll agree that the way our present system links healthcare to employment is appalling. Why was this done? If it weren’t for that and the government’s large share of the market, then insurance companies would be forced to compete for customers on an open market, and soon enough, they would be engaging in bidding wars for sick customers. That’s how dramatic the downward price pressure would be.

  2. molly says:

    I agree with you. My husband is 54. The health insurance companies consider him “uninsurable” and an “automatic denial”. He pays $1450 a month for a guaranteed issue policy. That is $17,400 a year for one person with a $2500 deductible. That is his only avenue for health insurance. I think that is an unreasonable amount. In order to get on Tennessee’s ACCESSTN, you must “go bare” without health insurance for 3 months. I hear horror stories as well, with people of all ages trying to buy health insurance in the individual market. Conservatives say that they support individuals going in business for themselves, but I don’t see any evidence of it.

  3. You raised an interesting point, Phil. Health care is grossly expensive for those trying to buy in, as, I’ve been there too.

  4. Anonymous • Disclaimer says:

    The runaway premium similar to the peak fuel price last year and left so many folks in despair insists on staying the course with the attitude ‘unchanged’, clearly this trend could bankrupt individual, business, and government. Now the government subsequently is tasked with these two main assignments, first, to address premium inflation, second, to expand coverage to all in urgent need.
    In order to cover all and not to add to the deficit, the public option can not set the same rates of private market, rather, it needs to have the function to keep it in check in terms of inflation, too. Unfortunately, this ‘unavoidable’ direction is aggressively being accused by the runaway premium, citing government ‘take-over’ .
    Under the circumstances the energy bill to determine human future and the other major issues is presently piled up, who wants to waste time making enemies ?, which also does not benefit the forthcoming election.
    On the other hand, to make things worse, critics say the savings from the proposed public option is not enough to meet the revenue goal. Furthermore, on another hand, some say ‘hands off’ . Where do these No tax, No saving and the like intend to force this reform to go ? The conclusion by ‘just-say-no’ is no doubt. Ironically, the Deficit-sensitive groups have a distinctive common ground, they all have a Deficit-driven background out of question.

    Of all choices, the best thing would be savings through efficiency. Considering the wasteful structure, the highest premium in the world, and the most expensive part of medicare, with the prevention / wellness program in place, an American style innovation, an ‘outcome’-based payment founded upon IT system may be enough to save more than 50 billions per year (500 / decade), both ‘improving quality’ and removing the unnecessary procedures (as pay is dependent on patient’s outcome). Young folks and advocates need to explain the notion of a pay for outcome agreement to the elderly misled by the disinformation.

    Unlike private market, this public option includes large-scale investments, these large investments still does not get the fair score, instead seem to become a source of acute conflict, even so, this common sense-based program needs to develop further as early detection goes beyond monetary value.

    In short, with the heartbreaking tears in mind (Nearly 11 Million Cancer Patients Without Health Insurance), private market also needs change and should join together to complete this reform , as promised, if not, the runaway premium only has itself to blame. Job-based coverage (indirect payment), mandate code, and ample capital might be favorable to the private market. And It can be said that fair competition starts with fair market value.
    Over time, supposedly, the public plan will concentrate more on basic, primary cares, and the private insurers will provide their clients with differentiated services.

    Thank You !

  5. mattswartz – insurance companies would be forced to compete for sick customers? Forced by who?

    Your statement defies simple business logic. The only way any for profit making concern takes on business is if it has a reasonable chance of making a profit. If you have a customer with a chronic condition that results in claims of $25k a year, you need to get back $25k + $1 from that customer or save yourself money by dumping him.

    To make a profit on those 65 and above, you need compute the possibility of illness among that population and then charge premiums that would cover likely claims plus profit. Without Medicare, even relatively well-to-do people would be bankrupted by insurance premiums. Health insurance is crucially different from property insurance. Your new built house is no more likely to catch fire 50 years from now than it is today. Your body, on the other hand, has a chance of suffering failure that ramps up every year and eventually hits 100% – the only question is whether the failure is quick and cheap or long and expensive. If you’re an insurer, cherry picking is just good business.

  6. Thinking about healthcare and listening to people talk (and write) about it, I’m struck by the perspective people– including me– have on it. If maintaining our health (and therefore our lives) is the most important goal in our lives, how is it that we expect the monthly cost of achieving this goal to be on par with our utility bills? “Look, I don’t want to sacrifice most of my income to maintaining my life, because this would diminish my lifestyle.”

    Another odd thing that strikes me more and more, is that this is not a debate about health CARE or the cost of health CARE but the cost (and source) of health insurance. Why do we need health insurance? What is it’s history and justification? Why pay $3000 per month so I can go to a doctor for the cost of a co-pay instead of paying the full cost when I do need to go? Why pay a middleman (private or public) at all? Other than a bankruptable incident like a life and death fight with cancer, why do I need the deep pockets of an insurance company/agency? And at $3 grand a month, how long before I have an emergency fund capable of paying for all but the most catastrophic events? And if I can’t pay the entire cost of that event, and I go deeply into debt and lose my house, but not my life, should I really have expected the fight of/for my life to pass with little more than a series of forms to fill out and sign?

    It just seems like healthcare (not to mention clean-living) are totally essential to our existence, and yet no one wants to take personal responsibility for it. We all just want someone else to take care of it without it affecting our ability to take a vacation or eat out several times a week.

    And one more thing, what if my well-healed progressive friends had their entire paycheck instead of three fifths of it? How many people, including themselves, could they help directly?

  7. Tom says:

    It is sad. The republican party trying to block health reform and protect a “system” that punishes entrepreneurs.

    I would love to see an estimate of much human captial is locked into unproductive employment situations soley due to health insurance reasons.

  8. Jack, I don’t think we need health insurance. Insurers are nothing but middlemen, standing between the payer and provider, and I think this explains why we pay so much more for healthcare than our peers, without getting better results.

    We do need protection against a bunkruptable event because we’re very likely to have one, eventually. Yes, you could responsibly save for such an event. You could also cost effectively drop dead. If you struggled to save $100k per person for a severe medical event – by no means an unusual expense – isn’t the joke on you if you never use it?

    I’m in 100% agreement that health care should be a personal responsibility. But that responsibility can be met in a number of ways – including taxation. Why should low income people get a skate on health care? If they can afford beer and cigarettes, they can afford to chip in for their health care. So tax beer and cigarettes. Everyone wants healthcare and everyone will use it eventually – so find ways to make sure everyone pays. But cut out the middleman.

  9. Insurance is expensive for a reason, and it’s not “greed.” I understand that the people with after-tax policies on insurance have it unfair compared to employer-based insurance, but having a “public option” isn’t going to fix anything. If anything our Medicare and Medicaid policies are the problem. Medicaid’s doctor reimbursement rates are very low and the paperwork is mind blowing; the result is that 52% of all doctors take in new Medicaid patients. Where does this leave the others who can’t get private insurance(probably because they can’t afford it), the emergency room! Thanks to EMTALA and Medicaid, our emergency rooms are crowded with Medicaid patients and just about anyone who seeks “free treatment.” Think about it, if all these people can just go to the emergency room and seek free treatment for anything, then when you have your catastrophic day and go to the emergency room your final prices the hospitals make up the money by charging you more! When they charge you more, those inflated costs are foisted upon the insurance companies.
    Another problem with private health insurance is “mandated benefits.” These mandates force insurance companies to have certain medical procedures and alike. The insurance companies price your premium around on that. Mandatory guaranteed issues also make insurance expensive because the State forces insurance companies to insure “small-group” policies, regardless of lifestyle choice in that group. About 20 to 25 percent of people who can’t afford insurance, cannot do so because of these mandates.
    What I find so amusing is that almost nobody even cares to look into the internal problems of health insurance. It’s easy to see a bad outcome and then radically declare change, but it’s not as easy when you do some research and learn how intricate our current regulatory matters are. If no one wishes to tackled the aforementioned problems(and there are more things that need to change), then your “health care reform” won’t fix anything.

  10. I’m a big fan of this site, and of the US paleocon & libertarian movements in general. While I find that my own ideology isn’t on all fours with yours, I very much respect your noninterventionist instincts.

    Nonetheless, I find your antipathy toward publicly funded/administered health insurance mysterious, in the same way a Chinese farmer might be confused by people who choose not to eat pork for religious reasons even though they’re starving.

    But to each his own, I guess. No one can accuse you of sacrificing principle for convenience, that’s for sure.

  11. mrmetrowest,
    Isn’t government just another middleman? If people choose to live unhealthily and not scrimp and save, can we ever save them from the outcomes of their choices? If you drop dead while jogging, and you never use your healthcare emergency fund, the joke is on your kids, who will inherit a nest egg for their healthcare and the care of your grandchildren.

    I think you’re mistaking inquiring minds for representatives of a political party. Your question is a good one. How much waste and opportunity cost is caused by the private/public insurance system? I’ve read that some insurers are racing to get on board with whatever public plan is devised. Why? What would happen if everyone in the country cancelled their comprehensive insurance and just paid for catastrophic coverage and paid their doctor for the rest? How much red tape and money would be saved?

    It seems to me that everyone is coming at it from the same starting point – the status quo. Your choice is the public/corporate status quo or the purely public future.

    Meanwhile, there are more sinister a-doings happening. The article on the UN children’s treaty is a chilling reminder of what a determined activist can slip through when the system is overloaded.

  12. Robert says:

    The current system is so fundamentally flawed that the only logical conclusion I can make about those who choose to defend it is that they are insane.

    As to the point about the critics of reform having never experienced the downside of the current system, I have to say that I cannot believe this, as I don’t recall having ever met anyone who did not have a horror story.

    My experiences with the current sytem over the past five years are as follows. First, my youngest brother–who has had serious health problems all of his life–decided to work for a while before he started college. As happens to many young people, the day he turned eighteen he was dropped by my parent’s plan, and because he was working for a small company that didn’t offer its employees coverage he found himself uninsured. Needless to say, about six months after his birthday he had to be hospitalized with severe case of pneumonia. A weeks stay in the hospital set him back a mere $50,000. Eventually he managed to negotiate the charge down to about $20,000, on which he is still paying payments. I might also add that his prescriptions nearly bankrupted my parents during the period he was sick and unable to work.

    Secondly, about three years ago one of my good friends from college woke up on a Saturday morning and discovered that he was unable to urinate. He immediately went to the emergencey room where it was discovered he had stage four bone cancer in his left femur, which had subsequently spread to his internal organs. By six o’clock that evening he was in the intensive care unit at a major cancer research center where he would spend the next three months. After a year of treatments–including a clinical trial involving stem cell therapy–he was pronounced cancer free. However, as his insurance through his employer had a million dollar lifetime cap, he was still left with bills totalling somewhere in the neighborhood of $175,000.

    Finally, my wife and I have long dreamed of starting our own business, and have saved judiciously so as we might see this dream to fruition. However, as many others have noted, health insurance is the one obstacle that we find seemingly insurmountable. We are both in our early thirties and in excellent health, but to date the cheapest quote we have received was $1650 a month, and this was only if we agreed to sign a waiver stating that the insurance company would not have to pay for any pregnancies or related expenses. Talk about someone else making life and death decisions for us.

  13. Jack, no matter how well you take care of yourself, you’re headed to the hospital someday. Old age is no one’s fault. And yes, your kids make out if you go fast – but do you really want to wonder if all those banana peels on your jogging path are there just by coincidence?

    Let’s make a (dangerous) analogy to public education. I’m for public funding of education. I hasten to add that I am against government monopoly of the delivery of education services. I’m for public funding because it’s in the interest of all that we have as few ignoramuses as possible and as many skilled workers and informed citizens as possible. Without public funding, a very large number of families could not afford a minimum 12 years of education for their kids. Rather than keep the financial burden only on those directly involved, I think it’s smart policy to fund education by broad based taxes.

    Likewise, many people have difficulty affording insurance now, and I maintain that without Medicare insurance would be unaffordable for millions of people over 60. You simply can’t profitably and affordably offer insurance to a population when you know that population is going to make a large and disproportionate share of claims.

    We’re all going to the hospital someday, and it can’t be free. But I think everyone paying a share through broad based taxation is smarter than the increasingly uncertain system we have now.

  14. Right on, Robert. I’m happy to hear that your friends and family have made it through.

  15. Jack, you raise critical questions. Health insurance used to be a safeguard against big ticket medical expenses. But now we all seem to end up in critical, expensive care at the end of our lives. So nest egg savings are so commonly eaten up my the medical expenses that the incentive to save is undermined. But I like your emphasis on personal responsibility and saving for medical expenses. The GOP used to tout medical savings accounts and this could be folded into that.

    I think two unspoken factors bear on this whole discussion.

    1. The main reason medicine costs so much, apart from malpractice insurance, is that medicine has advanced so far beyond what it once could do that it is beyond the financial ability of individuals to pay. It was only in around 1922 that going to a hospital actually increased your chances of a good outcome. Today, with the marvelous technology at our disposal the cost to recoup in a pay as you go basis overwhelms us. People rebel against the cost of what they know they can have, and as another commenter said, just don’t want to suffer the lifestyle shortfall of forking out what it takes.

    2. All health care options put forward by the government will be tailored to the expectation of personal irresponsibility. The government will inevitably design systems that presume the average citizen to be a semi-literate, smoking, boozing sluggard. So their system will inevitably penalize responsible citizens. Any reforms that give intelligent citizens options to manage their own health care will be rejected out of hand.

    It’s too bad that this has boiled down to another Democrat push for centralized government managed care. Steps short of that could be really useful. That last six months of life expense could be alleviated by a limited program, paid for by that tax on tobacco and beer. Some serious federal support for the cost of the cutting edge diagnostic tools like MRI would be significant to all of us, as sooner or later we all need them.

  16. Anonymous • Disclaimer says:

    The insurance companies have been cherry picking their customers for years. They have raised rates and lowered coverage systematically to increase revenues and minimize costs. Refusing coverage completely to anyone who has a pre-existing condition and canceling policies when a person is diagnosed with a serious medical problem.

    For the folks who want to purchase coverage, it’s not available or so expensive that it’s financially prohibitive. The purchase of prescription drugs is also unreasonably high. I recently paid $270.00 for 14 pills. I’m certain that the manufacturing of those pills was a few cents each.

    This issue must be resolved sooner rather than later. Our current system serves only the insurance companies and the prescription drug manufacturers, not the American citizens. Even the folks that have health insurance get hit with outrageous fees and co-payments for a hospital stay. Insurers sometimes even refuse payment after the medical procedures have been done, leaving the patient with unexpected medical debts.

    Illegal immigrants get a better deal than any American citizen who needs medical care because they get free services at the hospitals and Medi-Cal coverage for any future medical needs. Hospitals will process the paperwork for them.

    If an American citizen can’t pay, they’ll lose everything. 75% of all bankruptcies are due to soaring medical costs.

    This double standard benefits illegal immigrants at the expense of American taxpayers. We need to reform our system to bring a fair and equal treatment to all citizens.

    10 to 20 million Illegal immigrants need to return home to their country of origin where their country is responsible for their medical care, not the American taxpayer.

    Importing millions of people with no means of support is unsustainable and impractical for our country. At some point, we will not be able to pay for them all. California is already there with the burden of 2.7 million illegal immigrants pulling the state into insolvency. Your state will be next…

  17. MadMommy,

    1) Do you know the fundamental internal flaws in the system? Each one of them is very intricate, just like the Emergency Medical Treatment and Labor Act, which I described in a comprehensible form.
    I forgot to mention employer based insurance and tort reform, but those are two more intricate problems.

    2) Do you know why drugs are very expensive? Blame the FDA and the Kefauver Harrison Amendment.

  18. Mr. Meehan, in your sober argument, please refrain from using “Democrat” instead of Democratic. Let’s refraim from the name-calling that is not only clouding debate but endangering it.

    Mad Mommy, many American citizens have Medi-Cal too, not just the illegals, whom are actually being hired and paid by American citizens.

    My next door neighbor and mother of four worked at a Catholic hospital for 23 years and when she got breast cancer she was told that her “coverage” wasn’t complete because apparently they’d kept her at 35-39 hours a week in order to keep her from getting full coverage. She died in less than a year. We had fundraisers for her medical costs.

  19. Cieran says:

    Thanks for yet-another thought-provoking column, Mr. Giraldi. It’s always a pleasure reading your work.

    The solution of “group” insurance is an obvious one, and the larger the group, the easier it is to manage the risks, especially when risks are well-known from ample precedents (and the risks to human health are well-known, since mortality and disease have been around as long as humans have).

    The largest “group” would be the entire population of the U.S., which leads us naturally to single-payer programs and the advantages they bring courtesy of the law of large numbers. Large group plans are remarkably easy to make work effectively, since so much of the cost of health care is in fact manageable (i.e., keeping people healthy saves a bundle, as does giving due consideration to efforts to postpone a certain death by days or weeks). It’s not rocket science.

    So the solution is technically simple, and can be made cost-effective, especially when compared to the current morass that passes for “health care”. But we don’t want a good technical solution: we are more invested in the politics than in the medicine, and thus we each lose while the current system collapses under its own weight.

    Welcome to modern democracy!

  20. Mark says:

    Jack Tracey: “Right on, Robert. I’m happy to hear that your friends and family have made it through.”

    You missed the point, Jack. Robert relates stories about people forced to choose between death and crippling debt not to tell us that his friends and family were lucky to survive but to show us how ludicrous the American health insurance system is.

    And do you know why our health insurance bills need to be no more than 3-4x our monthly utility bills? Because if they’re much higher, business ceases to function in the country. You can’t run a business if the health insurers take 20% off the top before you pay salaries; you can’t run a business if your employees are bankrupted by medical expenses.

    Imagine you didn’t know what your taxes were going to be in any given year. Most of the time they’d be low…But for some percentage of people, the government would send them a $1 million tax bill without warning – that they’d have to pay on a salary of $50k. Overall, the tax rate – because of these huge expenditures – would be ten times what most people paid in a given year. Of course you’d be against such a system! So why you’d suggest that it’s an appropriate one to run in a competitive economy is beyond me. In fact, far more people are being prevented from starting small businesses today by the health care regime than would “go galt” if Obama jacked up taxes for people making over $300k a year.

  21. This is a really good google search:

    Oregon euthanasia cancer “Barbara Wagner”

    They said they’d not pay for her medicine, but if she wanted to die, they’d pay to kill her.

    Shine your flashlight towards the wall. There’s some handwriting there.

  22. I know people get ticked off by hearing this – and I’m not trying to be a smart alec – but in Ireland where I now live there is more-or-less universal healthcare available through taxes in the same way we pay for roads, firemen and police.

    * We are not sending old people to the gas chambers. We don’t allow abortion. Any crucifixes in the nurses’ stations don’t get replaced by hammers and sickles.

    * There are indeed complaints about the public system, but you can buy private insurance to supplement that (e.g. increased access to consultants, private rooms in hospital) for an annual price less than you would pay for a month in the US (that’s not an exaggeration).

    * It’s not perfect. Sometimes people go abroad for special treatments; but many of our complaints or debates might seem bizarre and petty to people in America. I’d welcome genuinely conservative “value-for-money” and common-sense criticisms of the system, or debates about medical vouchers, healthcare co-ops and so on. But it just seems like in the US people are being cynically used by corporate empire builders (not denying the Democrats are used too).

    * My American-born sister-in-law living here was commiserated with by her state-side family – they thought the fact she was having a third child would be a huge burden because of hospital costs. If you want America to be as child-and-family unfriendly as certain tofu-liberal cantons in California, I would think this is a great way to do it.

    I love America, but in all honesty, and with absolutely no disrespect intended to anyone elses’ patriotism, when I’m starting a family the insurance costs alone compared to the price of healthcare elsewhere mean that America – to use a somewhat crass analogy – is at a complete competitive disadvantage in terms of quality and cost of life.

    This isn’t just a matter of classical republican ethics (citizen solidarity, commonweal, the public interest etc.), but of national economic utility.

  23. Anonymous • Disclaimer says:

    First I don’t want the goverment running my health care, the bills that are in congress curently have little to do with health care and more to do with an idioligy.

    That said there are a few things that would go along way to reducing health care.

    1) Limit law suits / end def. med practice.

    2) Allow compitition , eliminate the state restrictions for Ins Comanies.

    3) Ins Compinies must cover every one who single actuary table ( that of all Leagal US Citizans ) no exceptions for goverment employees…they join the same system as every other American.

    4) Goverments role would be limited to
    A) eliminate Waste / Fraud
    B) POLICE the insurance companies.

  24. Dan W says:

    I live in Finland and we have universal health care paid for mostly by taxes. It is not perfect, but works well.

    Among the winners are mothers and children, our infant mortality is one of the lowest in the world and children get good healthcare up into adulthood. Also anyone with a chronic disease or need for expensive treatments, who will not be ruined for being ill.

    The losers might be elderly or low-income people with non-critical illness. If you are 70 and need a new hip, well, you’ll have to wait…

    There are private hospitals, too, if you prefer, and the government will chip in for a part of your costs, since you are saving the state money by going private. Private hospitals compete by providing faster and more customer-oriented service.

    You can get private health insurance, if you like. I assure you, it is possible for any Finn to spend like an American if he feels like it!

    It is not my intention to lecture Americans on how you should run your healtcare. Still, as I have always found you folks to be practical, can-do people, it is hard to understand why the practical issue of health care is so completely obscured by ideology on both sides of the argument.

  25. I got it, Mark. Did you?

    I still don’t see why we must have a middle man. If you want to opt into a shared risk scheme like insurance, fine, but the idea that being part of such a scheme is a right and even a duty– and that government bureaucracy is best suited to manage that scheme– just doesn’t stack up.

    The best government “assistance” program I’ve seen in healthcare since I started paying for my own has been HSA’s.

    Catastrophic insurance plans that can compete across borders, prudent (tax free) saving, and personal charity; what more do we need?

    I’m just starting to understand that medical care is critical to sustaining my life, and it’s just going to cost a lot of money, and I should just accept that and prepare for it. People fight life and death battles and it wrecks their finances. But what is money for, if not to sustain us?

  26. Aside from what I already have said, we should be allowed to buy out-of state health insurance.

  27. Catastrophic insurance is fine, but you need to understand that you are only going to get catastrophic insurance if your insurer believes it unlikely that you will have a catastrophic illness.

    Look at it from an insurer’s point of view. You want to sell insurance and make a profit. That means you have to take in more in premiums than you pay in claims. In order to set prices, you hire actuaries to compute the likelihood of the events you insure against occurring

    If you’re selling homeowners’ insurance, the likelihood of homes catching fire probably doesn’t change much – it’s low and remains low. With the possible exception of Southern CA, there is not a ton of variation among dwellings as to their likeliness to catch fire.

    Now imagine you want to sell health insurance. You set your actuaries to work, and what do they find? The likelihood of catastrophic illness rises every year, and after 60 or so the pitch of the rise steepens. It eventually hits virtual certainty. Further, if your actuaries look at the backgrounds of certain people they’ll find that some people have greater risks from the outset: people with type 1 diabetes, women with multiple breast cancer victim relatives, etc etc.

    To run a profitable insurance business, you must either cherry pick, or charge premiums based on age or condition that will approach the full cost of paying in full for treatment. If you spread the premium cost evenly among age groups, the high cost will probably deprive you of your cash cows – young, healthy people who don’t make claims.

    This business model does not work with modern medicine because it can’t. The insurance model is about taking a payment to guard against an unlikely event. The payment will be small relative to the payoff if the unlikely event occurrs. As the event goes from unlikely to certain, the payment must grow until it equals the cost of damage from the event.

    Suppose there’s no Medicare – how much would catastrophic health insurance cost for someone 65? Given the likelihood of such an individual racking up a $100k medical bill in the next 20 years, the cost would have to be several thousand dollars a year. How many retired people could come up with that? And that would be just for catastrophic – how about all the non-catastrophic care that allows us to lead high quality lives into out 80s?

    As other posters have said – put the ideology aside. This is about business, about purchasing services and getting the best value for money spent. Our country pays too much and gets too little.

    ps – a note about homeowners’ insurance – if you make too many claims, your insurer will dump you.

  28. So this would be good business for whom? Providers, patients, or middlemen?

    Fellow readers, witness the Progressive in his native habitat– churning through the details without examining (or explaining) the basic assumptions that underlie them.

    One basic assumption is that the only way to purchase medical services is through an intermediary, who will determine what purchase price– in the form of premiums or tax revenue– and what level of service for each individual, will sustain the intermediary. (Remember that cost containment/sustainability are stated goals of current public proposals, even though history suggests that this is an empty promise.)

    Yes, an intermediary allows participants (willing or otherwise) to share costs, but it also creates new costs that must be shared (red tape for one), and it creates limitations. If funding has a limit– whether total premiums or tax revenue– then there will be a limit to the total services that can be purchased. If you try to compensate with price controls, then you will inevitably have a shortage of available services. Of course, a third option available to a public system would be ever-increasing public debt.

    Would you rather some seniors pay through the nose if they’ve had 3 heart attacks, or would you rather have all services limited based on some non-monetary needs analysis? A second basic assumption is that the latter scenario would be fairer.

    Please, put the ideology aside. This is about business.

    p.s. “The losers might be elderly or low-income people with non-critical illness. If you are 70 and need a new hip, well, you’ll have to wait…” -Dan W

    p.p.s. I don’t see any reason why the current “system” needs to be championed or maintained. I’m also not convinced that a wholly government system would deliver better, cheaper outcomes (leave aside the libertarian concerns). Why the rush to make it happen? Those in favor of this path began the debate, and therefore have the advantage of setting the terms. We’ve seen this before. I’m sure once the path is irreversible, opposition voices will find their footing.

  29. Jim says:

    Jack, I doubt you have seen hospital bills people run up for treatments of even relatively minor procedures, let alone major events like heart attacks, major abdominal surgery or anything similar. God forbid you get cancer. Setting aside even a $1,000 a month for many years will not protect you for more than one of these types of events. The cost structure is completely out of whack, and telling people to simply cut out the middleman and simply save up for future medical expenses is totally impractical, and probably a sure way to set yourself up for a future bankruptcy.

  30. Let me suggest that all the talk about “gov’t vs. free market” health care is nonsense. There is no free market in health; the market is dominated by monopolies and oligopolies. That is, it is dominated by patents, licenses, and anti-competitive consolidation in the insurance industry.

    Patents on medicine and equipment (on which the health care industry is now dependent) create gov’t-protected monopolies. The signature of a monopoly is that prices rise independent of actual services provided. This is why medical care has escalated from 8% of GDP 20 years ago to 17% today–and continues to rise. Licenses for medical practice and facilities restrict the supply and thereby put pressure on prices.

    And consolidation in the insurance industry has made this market anti-competitive.

    The single payer systems work because they function as price control mechanisms. That is, they “negotiate” with the monopolies to fix prices. This is a legitimate response to monopolies.

    The current health care bill does not address these problems, and so will fail to the extent it succeeds. That is, the more people it extends coverage to, the more pressure it will put on prices, which will insure its own collapse.

    We may think licenses and patents are a good thing, and maybe they are. I happen to thing there are proven alternatives, but nevertheless they create monopolies, and cannot be considered free market.

    My own free market and distributist response to this problem is at

  31. Aaron says:

    I am probably more fiscally conservative than anyone on this magazine or in the forum. I am completely free market except in medical care. The US pays too much in medical care because of lack of medical care or bad insurance. I would rather have a single payer system than nothing at all.

    I have, as a professional, great insurance, but it has been a nightmare with dealing with administrative issues since I was diagnosed with a rare lymphoma in 2001. Because my insurance went up $4000 in a single year, I had to switch to a cheaper insurance. The switch has been a nightmare. It has been two months without any cancer treatment because my new system is so backed up. They won’t even look at my previous medical records, so I have to go from point A to B in a very slow, expensive measure. They could save $10,000 by simply having a doctor look at my records and put me back into treatment, but I have to go from point A to B because insurance requires it.

    I am very bothered by the Republicans who argue that they want business to get away from providing health care insurance (it is part of my salary and part of the reason I took my job). They would like clearinghouses and competition, but anyone getting older or in my position would receive very expensive insurance that does not cover pre-existing conditions. A clearinghouse would only benefit the young and never ill. Health insurance is not car insurance and should not be seen as such. Health insurance will never go down–once ill, it is part of your total history.

    Many of the people complaining about these plans seem to be worried about what will be taken away from them. Instead, when you look at the plans, they are all designed to bring down some costs by bringing more people in and having more security. I am very close to moving to the Democratic Party over this single issue. I disagree with everything (except some social issues), but Republicans tend to be suggesting very dangerous ideas that would hurt me badly.

  32. Louis says:

    @MattSwartz, on August 9th, 2009 at 7:54 pm

    (1) Employer based insurance happened essentially by accident. The government put caps on wages during World War II, and given the scarcity of workers employers had to find other incentives to attract talented employees. So they offered health insurance as a benefit. In the sense of being the government I suppose history could say you’re technically correct given how it started.

    (2) As far as insurance companies competing for the sick, I don’t entirely agree. To compete for the sick you would have to change the model that exists right now, which effectively groups people by how healthy they are, instead of together (spreading the risk).

  33. Louis says:

    Rationing occurs any time you have a finite resource, but a perpetual demand. Rationing occurs in healthcare–it’s not a question if it occurs, but how–given that healthcare is very much a finite resource and any healthcare system will have rationing.

    The United States rations healthcare largely by an individuals ability to pay. For example, if you have insurance, you could find yourself in a situation where your insurance company won’t pay for a treatment and then you’re on your own. Those who cannot afford insurance tend to prolong treatments until they become emergencies because they cannot afford treatments–the ER you cannot be turned down.

  34. KXB says:

    I got a letter from my insurance company the other day that my monthly rate will go up 19% starting next month. I have not gone to a doctor in 2 years. I work in my uncle’s small business, and he reimburses me 100%. But, I have had very small increases in pay for the past couple of years. Basically the choice is between covering my health insurance or a raise. So, while on paper it looks like my benefits are increasing, I am not seeing any real increase in wealth. And as a small business, we are at a big disadvantage against big business competitors, who can offer employees group insurance.

  35. Anonymous • Disclaimer says:

    Primary doctors spend about 40% of their time dealing with insurance issues because there are 1700 insurance companies out there, each with a dozen or more policies available. This is where it starts to get tricky.

    Because insurance is so expensive, employers often switch insurers annually to take advantage of some new firm trying to break in and offering a discount. Well, nevermind the effect this has on doctor choice for the moment, the cost to the provider to keep up with these changes is immense.

    Then, at the point of treatment, the provider has to confirm the formulary and treatment plan of the insurer before he can treat the patient to make sure the patient gets the best that he/she can afford.

    However, the insurers reserve the right (is it a right?) to change the medical coding your provider entered at the time of treatment after confirming that it applied at the time of treatment. So, you get a new bill six months later and complain to the provider who then has to try to work with you to get your money back, costing more money. Imagine if Shell sent you a bill six months later for gas you bought at the gas stand price but they suddenly decided to change the price after the fact. This happens every single day in every city in America.

    I don`t think we all will ever agree on what is best, but we all have to agree that the current system is absolutely wasteful and inefficient. I dare say an economist could not come up with a less efficient system if paid to make one.

  36. Ottovbvs says:

    I’m retired from a long business career, ultimately running some fair sized companies. I’m on an advantage plan but my wife is somewhat younger (not a trophy bride) so I have to buy her health insurance with highish deductibles and co pays at a monthly cost of $1.300. I became a convert to major reform in the mid 90’s when all I could see was 10% a year increases into infinity for a workforce of several thousand and I realized that at some point we would not be able to shuffle any more costs onto employees….we’re now essentially at that point which is why much of American business has changed its outlook. Obviously, we’re going to have to make bricks with the available straw so the Obama plan as I understand it’s main elements seems to make reasonable sense. Even the insurance and Pharma industries have bought in either because they realize this is unsustainable or they fear what might happen if the system collapses in a few years time. Fundamentally, having a patchwork healthcare industry that costs twice as as much as everyone else’s, doesn’t cover everyone, impedes labor mobility and damages competiitiveness makes no sense economically or socially. For some reason the Republican party refuses to accept this obvious reality and what’s even more perplexing it’s foot soldiers many of whom are in a similar precarious position to the author of this diary are willing to demonstrate against or silently oppose any change in the status quo. It is truly insane and self destructive conduct but that’s the direction the right in this country have chosen to go in and very often with the most grotesque and reckless scaremongering. We’ve become inured to the horror stories from the UK and France which both have good systems that I’ve personally experienced and have now moved onto death panels. Frankly, the right generally and the GOP, which I’ve tended to vote for most of my life, are behaving with with what I can only call reckless stupidity. It’s depressing and yes appalling.

  37. DR says:

    Because of your prior medical conditions, insurance companies rightly believe that you will cost them considerable sums. Yet, you think you should be able to nonetheless buy affordable insurance. This can only be accomplished by spreading your cost to someone else. In the health insurance world, this usually means younger workers. Given your age, I assume you have a home and accumulated many worldly possessions. Are you prepared to share them with the young couple trying to pay rent on a one bedroom apartment while saving money for a down payment on a home they hope to buy someday? How about paying to repair bills on the young kid’s car when it breaks down. Why is health insurance so different. We have Medicaid for the poor. You chose to be self-employed. Now live by your decision, or get a job with a company that offers a group plan.

  38. Z says:

    Jack Tracey,

    I don’t like the middle-man either, but the high-deductible, HSA system you are suggesting still has a middle-man. I tend to think that HSA’s work fine, for people who are healthy and make at least double the median income. Then, it really is a choice between lifestyle vs healthcare, rather than basic, necessary expenses vs healthcare. Otherwise, some people will save a good percentage of their income, all of their lives and still not have put aside enough money to cover the routine care for a chronic disease. Of course, more people could afford to save for their own insurance if they weren’t paying for basically gold-plated elderly care a-la medicare. Naturally, seniors are the biggest opponents of reform.

  39. “If people choose to live unhealthily and not scrimp and save, can we ever save them from the outcomes of their choices?”

    What if they get hit by a bus?
    What if they are born with spina bifida?
    What if they get anal cancer like Farrah Fawcett?
    What if they get injured on the job?
    What if a woman gets cancer because she took hormone replacement therapy as advised by her doctor until new studies came to light?

    Not all illness is the result of choices, particularly the last illness – the one that kills you.

    Health care is a hard problem that will not be solved by any particular ideology.

  40. Ron says:

    The insurer is indeed a middle man, but the idea of insurance is one of the quintessential elements and greatest achievements of market economics. If everyone were to self-insure, there would be an overwhelming dead-weight loss on the economy, because everyone would cut consumption drastically to accrue savings for a cost that many would never actually accrue. This is true of home and auto insurance, as well as for every commercial operation and transaction. From mortgages to mergers & acquisitions, investors rationally prefer insurance protection from a “middle man” rather than trying to self-insure.

    Health insurance is different, but not that different. An economy without health insurance means people have to save enough to prepare for the worst, and that means a dramatic falling off of consumption. It also means a higher reluctance to take risks, and innovation and entrepreneurship suffer.

    The American system of health insurance is crazy and is killing off businesses and entrepreurship, and bankrupting consumers. It has to be fixed and made more rational, or we are all going to suffer the economic consequences.

  41. All of you who are responding are assuming that the world without middlemen would look exactly as it does today, with end-user prices increasing faster than actual cost of care. Either that, or you are stuck on this idea of government as the public defender against the insurance “monopolies”, whom government’s own byzantine regulatory requirements (for starters) help to maintain.

    Can anyone point us to an authoritative (and objective) history of how insurance companies and the insurance industry came to look like this? What was the roll of government, including Medicare/Medicaid, in creating this dragon that it is now telling us only it can slay? Could the insurance industry titans exist without government? Could the healthcare industry exist without insurance?

    Everyone, including me, knows people getting screwed on a regular basis by the middlemen. Just ask a doctor. Is the answer putting more laws between you and that doctor?

    How beaten down are we?

  42. Anonymous • Disclaimer says:

    Beaten down? Nah. What we’re seeing is the public voting in great numbers for policy that might actually work for them. I would call that liberating.

    Jack you say this is business. We should remove ideology from the discussion. It’s dollars and cents.

    Fine. I’m a consumer and I’m fed up with the products available to me on the open market so some friends of mine and I have decided to open our own business to create products that we like and need.

    That’s the American way, right?

    There is simply no reason the consumer cannot band together and self insure through the government. We do that for our common protection, we do it to create roads, we do it to educate ourselves. There are private alternatives to our own business and that’s fine. It’s healthy even to give more choice.

    We have a mechanism in place that works very well to provide insurance to a huge sector of the populace. It’s financing is sick so me an my friends could take that mechanism and build it into our own company setting our own sliding scale rates of premium and establishing our own best practices our providers would follow.

    Medicare works to deliver what it’s supposed to. We are going to have to fix it’s finances anyway so why not open it to all of us as a public option, introduce sliding scale premiums into it’s revenue stream and work to institute the waste and fraud already identified by the admin.

    Open to all on a sliding scale, we could do away with Medicaid and all the state programs that provide children and low income insurance. We could even do away with the VA and just give Medicare to the vets for free which many would like so they could actually see their family doctor and use local facilities rather than driving to who knows where to get their free care.

    Think of the budgets of all those disparate programs that could be done away with. Think of all the savings just on administration of them let alone the savings on the provider end for not having to chase down a million different insurers and codes and practices.

    That’s good business when the consumer is the citizen. It’s also the least disruptive way to get everyone in the system. It also happens to be the right moral thing to do.

    Yes it is business. And we are the consumer. And we are not happy.

  43. Anonymous • Disclaimer says: • Website

    I live in the UK.

    In September last year I was diagnosed with a non life
    threatening condition. It was a long battle to get a diagnosis. I am female, therefore as the symptoms were multiple and did not fit a particular accepted criteria, they were deemed to be in my silly, little female head. Since diagnosis, I subscribe to a forum which has an American division. Some in the USA encountered the same problem.

    This said, in my horrendous pathway towards a diagnosis, I had two echocardiograms, wore both Holter and Recollect monitors twice, had an angiogram, a chest xray, a CT scan, blood tests, was hospitalised twice and so on and so on – and it cost me nothing!

    I am now on meds. I pay £7.20 per 28 days for drugs at a cost, not market price of £9.81. 60% of the UK population do not pay for drugs, either because of their financial situation or their illness would be life threatining without prescribed drugs

    I do not hold a left-wing political view, nor rightwing, middle of the road, but perhaps veering to the right. I do not believe that my health care should be a product of political ideation. Good health is my right. If my government looks after me, I am grateful for it. I would not like my health to be dependent on my ability to pay health insurance or on the whims of a pharmaceutical company.

    Yes, the NHS is flawed, especially since in recent years it is attempting to emulate the US model and has become swamped with management layers that grow daily at the cost of front line care. Thanks Dear Labour government! NICE is not very nice at all, but to pay for this **** front line care suffers again!

    I find it ironic that in the land of the free, where anyone can become president, if you do not have the means to pay for the basic right to good health, you are denied it!

  44. Anonymous • Disclaimer says:

    A Simple Proposal:

    1) Create a very basic, high-deductible, catastrophic-event government health-care policy that pays for major medical events only. Include everyone and pay for it with taxes. No one would ever again lose their home or be denied life-saving procedures. It would be cheap because it would be “single payer” and would include the whole pool of healthy and unhealthy people, sharing the risk universally. Billing would be simple for hospitals who would be guaranteed payment and the cost of providing health care would be taken of the backs of businesses.

    2) Middle class and wealthy consumers would pay for routine illness events out of pocket, just like getting your car repaired, or they could purchase add-on insurance from private companies, as they choose.

    3) Poor people would get extra coverage for routine illnesses as welfare or in free government or charity clinics. There will always be people who are so poor that they can’t contribute anything.

    Wouldn’t this solve everything at modest cost to the public, or I am just simple-minded?

  45. Ron, health care is vastly different. The home and auto repair markets are free markets, so the insurance companies can more or less rely on these markets to control costs. The opposite is true in health care, where costs are dominated by the pharmaceutical and equipment monopolies through patents, and the supply of personal is limited through licenses. The market is not a free market. The more money you supply to monopoly markets, the more you increase prices without any appreaciable effect on supply. This is simply economics. Patents and licenses are gov’t created and protected monopolies; you cannot have a free market in the face of monopolies.

    If you want a free market, you must get rid of licenses (or at least greatly expand them) and patents. If you want patents and licenses, then you must either control prices or watch the market spin out of control until it collapses. There is no third choice.

  46. Well, I think it’s settled: all thinking people agree: “Universal Healthcare for All!” The people have spoken (at least the trolls have), and the greed of the market has left us with no choice.

    When an army of idealogues… err… excuse me.. practical people set out to change minds on the internet, they can sure cover a lot of ground.

  47. Ron says:

    John Medaille–

    Ironically, perhaps, I agree with nearly everything you say; that was what I was nodding toward when I said the American system of health insurance is “crazy and is killing off businesses and entrepreurship, and bankrupting consumers,” and that it has to be made “more rational.”

    I was perhaps too cryptic about that because the main thrust of my comment was directed at Jack Tracey’s warped and naive comments about insurance as “the middleman.” At my old firm we did a ton of work on M&As and large scale real estate development, and believe me, nothing moved out of the conference room and out to the street without substantial insurance and/or securitization. It just amazed me to hear such ignorance about basic market functions on a blog that is supposed to appeal to conservatives.

    So I think health insurance is similar to all other insurance in that economic self-interest leads people to very rationally look for ways to spread risk, the basic function of all types of insurance. And, as with much of the market, individual self-interest dovetails with social benefit, because that spreading of risk makes possible the innovation, entrepreneurship and consumption patterns that define the modern market system.

    It’s also true that our current health insurance system is an impediment to the innovation, entrepreneurship and consumption patterns that it should be facilitating. So, we need an honest conversation about how to address that. And Jack’s recent silly pretense that trying to have such a conversation amounts nothing more than “trolls” and “an army of ideologues” just goes to show how far we are from having that conversation.

  48. Ron, the “conservatives” are in a trap. In order to have a “free market,” they must destroy the monopolies, but the monopolies are their backers. Hence, they can only make up fantasies about death panels (

    The liberals are in a similar trap. Without imposing price controls no plan can do anything but feed money to the monopolies. The upshot is that the conservatives have nothing to conserve and the liberals have no path to liberation.

  49. Anonymous • Disclaimer says:

    Everyone who is now howling about health care believes they have great health insurance, and the claim to be satisfied with it…until they actually have to use it.

    It doesn’t take a genius to do the math. Sometime in the next decade, the cost of health care in the United States will rise to 4.5 trillion. The math is in the liberals favor. All conservative plans pass the costs almost entirely onto the employees, and they largely neglect to not that for decades, employee salaries have also been kept low by giving these tax free benefits. Any conservative plan is going to meet with this fact. That employers raise employee salaries because of the decades of savings in payroll that this benefits has allowed them. Cutting a benefit is still in every sense, cutting salaries,

    Who gets the best health care in the world, The French. They have a single payer system, but that is where the government involvement ends. A system of laws in which doctors have the final say in what the insurance companies will have to pay for, and a set of laws that allows private insurance companies to administer heath care and process claims has created a system that is paid for publicly, but is completely run by the private sector. For all of the assertions in America, the French are not very fond of letting government do much of anything when it comes to their private lives and health. So they have a system in which the vast majority of people are covered, and and the health system is pretty much completely private,

    The French do not have ,waiting lists to see doctors. In fact, the system is so doctor friendly that the French have 3.9 physicians per 1000 citizens compared to the 1.6 per one thousand in America. And this number of doctors per`citizen in the U.S, is falling. Largely because in America, the doctors have the last say in the treatment of their patients.

    This is largely why doctors oppose Obamacare, but rather, according to most recent polls, prefer a single payer system that removes the insurance companies completely. In 2004, polls showed that only 49 percent of doctors supported a single payer system, while 49 percent opposed it, By January, 2009, the same poll taken by the same medical journal found that 59 percent of doctors want a single payer health system and only 32 percent oppose creating one.

    Even more to the point two recent polls indicated something rather shocking when one looks at the media coverage.

    The first poll, a Rasmussen taken between August 15th-17 indicated that any government legislation that does not include a public option has literally no public support. One with a public option does.

    The next poll, which was taken concurrently with the Rasmussen by NBC found that 21 percent of Americans think the health care system needs to be completely overhauled. 39 percent think it needs major reform. 31 percent think it needs minor reform. 7 percent think nothing needs to be done, and 2 percent think are uncertain. This comes close to the preference of the medical profession for single payer. 60 Percent of those polled believe that the current health care system is massively broken and needs some form of major government action to fix it. Another 31 percent still think the system need fixing, albeit minor.

    The private sector has had 80 years this year to get things working correctly. The first private health insurance plan was started by teachers in the wake of the crash of 1929. Doctors and hospitals in Texas offered the plan, because the depression was sending their businesses into an economic tailspin. For a small weekly fee, teachers would be offered complete medical care. This raised enough money to keep the hospitals opened, and the doctors offices in business. This company is now Blue Cross/Blue Shield.

    Recent studies have also indicated that it is the to 5 percent of income earners who are “spending” about 50 percent of the 2.5 trillion dollars that the nation spends on health care. But they are not paying for it, It is of course, largely paid for by their employer through their health insurance policies, which are usually far more generous for those in the higher income brackets than for those in the lower.

    Of course, someone has to pay for that top 5 percent who use that fifty percent of health all the health dollars spent in the U.S. Largely through very generous plans to those in that top five percent. These plans cover anything from botox, to sauna, to yoga classes, to seaweed wraps, as long as they are being done in a medical facility or doctors office,

    Who actually pays for this stuff. Of course it is the rank and file employee who has the average health plan offered by the same company who never quite manages to spend as much on health care as is actually paid for them in the total of employer and employee contributions. It is rare that an employee of a company actually uses up the 14,500 a year that is the total contributed for their health care. As is usual, the current system is a trickle up system, that is simply too complex for the average person to understand. The vast majority of Americans would be better off if they got the employer contribution in cash, either tax free, or adjusted for the difference if it were taxed. As it stands, insurance companies deny ten percent of all claims, but more to the point, once a claim goes over that average of 14,500 per employee per year, the rate at which claims are denied is a rather large fifty percent, and this does not include those claims that are partially denied,

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