Comments

The HCR PR war continues: pre-existing conditions — 31 Comments

1. Theees is BEEE ESSS.
   In Michigan, Blue Cross will/must issue an individual contract to anyone who applies. To avoid the phenomenon desired by the O-bots, where the guy stops by the insurance office on his way to the Cleveland Clinic, expecting to swap $500 for $250,000 in bills and then drop the plan, BC excludes existing causes for six months and then picks them up. When I did individual health insurance, we would send the non-qualifiers to BC. Didn’t seem to ruin BC.

2. I don’t know, Neo, why do we call them “companies”?

   I mean , assuming they were businesses one would have to assume they operate in a “market” and given the real world environment in many states some of these insurance “companies” are little more than de-facto monopolies.

   Here’s the thing: they are involved in HEALTHcare. Arguably this puts an obligation on them to have concerns other than mere profit, and if they can’t handle that perhaps they should get out of the game. Maybe a free-market model doesn’t work best in health care after all, though of course that too is strained: we don’t have a “free-market” in healthcare in the first place, we have a mixed socialist/monopoly model and given how it works in this country probably the worst of both worlds. We don’t have enough “socialism” for that to truly mean anything in terms of coverages, and we have too many de-facto monopolies to call it a “market”.

   What a mess. See why I say I’d go one way or the other (total free market, or else public option or “single payer”), that this “compromise” plan of Obamas is a disaster, and that doing nothing as an option will soon be taken out of the governments hands as well.

3. It’s for the children… Oh, wait, wrong story. It’s racist. It’s discrimination. It’s mean spirited. You’ll starve old people. We’ll save money. I’m from the government and I’m here to help.

   What a crock.

4. “”they are involved in HEALTHcare. Arguably this puts an obligation on them to have concerns other than mere profit””

   So ummm…The carpenter is involved in shelter. The farmer and grocer are involved in sustenance. The gas station is involved in critical transport…

   Defeating the communist Soviet Union is proving to have been a major mistake. We had their empty grocery store shelves and peasants living in squalor on tv from time to time to remind us how wonderful free enterprise really was compared to their govt planned utopia.

5. Rep. Schultz-Wasserman 20th District Florida was on FOX the other day extolling the wonderfulness of Obamacare. Of course her arguments were based on nonsensical data (she earlier said that there was no such thing as the forced purchase clause), then she went on to say that there is nothing anyone can do to repeal it. Translation, we are the ruling class and you are the peasants. As many have noted; Obamacare was never about Healthcare. If it were there would be no need for the partisan sales pitches such as those presented by Comrade Sibelius. BTW is anyone besides me convinced that Congresswoman Shultz-Wasserman is a genuine psychopath? She can lie without emotion and is indifferent to the amount of people who will be hurt by Obamacare.

   Another BTW, I’m thinking of re-naming the Democrat Party the Neo-communist Party in recognition of their newly acquired authoritarian propensities and self-proclaimed social station. Feedback anyone?

6. SteveH:

   I presume you are, then , willing to revoke the Hippocratic oath? I mean you know, people’s health is just like any other good, no different than going down the street to enter the tanning parlor..

7. Brad
   The hippocratic oath refers to doctors.
   The insurance companies must make a profit or they go out of business and can’t pay claims. So, in the spirit of your sneering and unfair question about the hippocratic oath, so you want insurance companies to go out of business and not be able to pay claims.
   Hell, if they do that, the only other choice is total government takeover….
   Say….

8. Dear Richard:

   I really don’t care whether healthcare is private or public, I’d actually prefer a system like Great Britain’s where people have a choice to have both, but that’s beside the point.

   I consider health care to be unlike most other goods in that everyone will need it at one point or another in their lives, and just like food production – if the private sector shows it can’t handle people’s needs in this matter I have no issue whatsoever with the government providing it instead.

   We no longer live by our constitution and people like you are of the type that chastise libertarians for being unrealistic , at least in terms of foreign policies and national security. The intellectual picking and choosing and the hypocrisy in not being able to recognize it is astounding. I’m a pragmatist, not a free market or socialist ideologue and like I said, we better get this right somehow or the current system will collapse anyhow and in that chaos don’t be surprised if you end up with a single payer system.

   And the idiocy of the current denizens of the “right” will be as much to blame for that as anything.

9. Brad.
   Conflating health care with health insurance is confusing.
   But you knew that, didn’t you?

10. Richard:

    Since it is insurance that often determines who gets healthcare I don’t see how you can separate one from the other, but you know that, don’t you?

    Do you have a point, or don’t you?

11. Brad.
    See my description of how Blue Cross works just fine in Michigan.
    But insurance doesn’t determine it. Insurance determines what they will pay for–read the contract–and you can pay the rest. Few contracts have such high deductibles and co-pays that the “rest” will bankrupt the insured. And those are bought with eyes open and huge premium savings. “Savings” does not mean a fancy new car, but…savings as in a bank account. Or, with government help, HSA.
    If pre-existing conditions are a problem, Blue Cross in Michigan has it figured out. If you want to stand behind the door letting insurance pass you by until you have a big dollar op coming up, don’t expect your neighbors to pay for it along with the premiums they’ve been paying for their own insurance.

12. What I believe is critically needed in health care is competition based on price and quality of results. Price as in individual payment for individual service. There is no price competiition in health care, none. That, more than any mandate, would bring costs down in a flash. Insurance or gov’t payment per unit of service can do nothing, nothing, to improve quality. The worst doc in the country gets paid exactly the same as the best doc, for the same unit service.

    Everything comes at a cost. Even those who conflate insurance with care know that. It pisses them off, but they know that. Do they know about moral hazard and adverse selection though?

    Insurance shoud be insurance, which health insurance presently is not. I know I know it ain’t gonna happen. But our present health care system is not and will not collapse into chaos, any more than letting the bankruptcy courts deal with GM would have thrown tens of thousands out of work overnight. That is alarmist tommyrot, meant to spampede the ignorant among us, who are legion.

13. coupla typos–sorry.

14. Tom:

    The rising costs say you are wrong.
    It’s not inevitable, we could argue over which legislation to pass or regulations to impose or relax, but doing nothing is not an option. Sorry, current system =broken. Obamacare= unlikely to make a difference in cost structure, might make it worse.

    You can call me all the names you want, but you can’t argue with healthcare cost inflation which is at this point starting to resemble the ridiculous rise in home prices during the housing bubble.

15. Called you no names, Brad. You don’t get the points of my post, though. BTW, I did not disagree with you that our current “system” ain’t working wonderfully, did I?
    I do not know what you think drove the housing bubble, but I think it was largely the government, which includes the Fed and Fannie/Freddie. Once again, think moral hazard and adverse selection.

16. I just finished reading David Dranove’s “Code Red,” which is a marvelous analysis and historical account of the American health care industry. Before saying anything else, and for what it’s worth, I highly recommend it. I’ve read quite a few books on the health industry (I took a class in health care economics and policy in a former incarnation), and Dranove’s is in the top five at worst.

    The essential point that Dranove makes is that there are no magic bullets in the health care sector (just as elsewhere). I come from that perspective, which is why I’m never able to accept Brad’s either/or. No one has shown in a way that I find convincing that a single-payer system is superior to our current “broken” system. Nor has anyone shown that a radical libertarian solution would be superior, and if so, possible (I believe single payer is possible, unfortunately).

    In a way, our health care sector evolved like the common law – it was a series of piecemeal, ad hoc policies piled on top of each other, incrementally tinkering and correcting and tinkering the tinkerings and correcting the corrections. In short, it’s a blooming mess.

    It isn’t that I oppose efforts to clean it up, it’s just, I suppose, that my definition of a pragmatist is different from Brad’s. My conception is Burkean, and no Burkean approach to a policy realm would conclude “Destroy current system X with either extreme policy Y or extreme policy Z. But destruction it must be.”

    So I think tinkering is best, because, again, I do not think the current system is broken (no system with our cancer survival rates can be described in that way, unless hyperbolically or rhetorically), and because, from my Burkean pragmatist perspective, totalistic solutions to massive, intricate, complicated, messy policy conundrums are almost always disastrous, killing the patient with the cure – and at this point, tinkering in a free market direction is, in my view, the best way to go (breaking down state barriers, some tort reform, working on some way to make the tax grid less punitive for small businesses and more encouraging of cost transparency, and overall counterbalancing the centralizing coercive trend with a decentralizing trend, etc. But above all, repealing Obamacare).

    Whether or not Brad is right that health insurance companies must operate under a special moral imperative, the same would follow for the government if it took over. And I am unaware of any evidence that shows that single payer systems operate more altruistically, or hippocratically, as it were, than private companies. But however one slices the empirics, the point is that “compared to what?” is the question the pragmatist asks.

    If Brad’s answer is that the British NHS is a good enough response to “compared to what?”, then I’ll happily stick with our current “broken” system. If he answered, “Something like what Singapore has going on,” I might listen a little closer, though I’d still be leery of going whole hog, for reasons already stated. Be that as it may, I’d be interested to hear why Brad is so certain that the British system is obviously superior to ours.

    Overall, there is a kind of disconnect that shows up in this debate, in that conservatives (such as myself) tend to dread extreme centralization more than imperfect social realities – as Burke put it, we tend to view it as being prudent to not blow too much top over “abuses” until they “fester into crimes.” That has benefits, and, yes, drawbacks. I’ve already conceded to Brad that my conservative-style prudence may be leaving me with a blind spot in this case, and I retain the right to change my mind. In any case, the disconnect comes because those not of a Burkean temperament have the tendency to conceive of every “abuse” as a “crime” – or, in the terms of this debate, to conceive of “flawed” systems as being “broken.” That too has its benefits and drawbacks.

    We better be sure, thus, what it means to have a “broken” health care system (always attended by the shadow of “compared to what?”).

    One final note: Lets say that I believe that a health care system such as ours (with several million uninsured) is fundamentally more just than the British and Canadian single-payer systems (with everyone covered, at least in principle). Leave aside that me and Brad certainly disagree on which is more efficient. I think our system is morally better than Britain’s and Canada’s – and here’s my question:

    Is it possible for me and Brad to have a real debate on the matter, given that? (I’m sure everyone can see the thrust of my line of thought – I suspect that greater than 50% of what is in dispute in these arguments is not “pragmatic” but moral, even though it is usually framed in utilitarian terms).

    Just thinkin’ out loud.

17. kolnai
    You have two issues here, at least. One is the possible confusion between uninsured and having no possibility of care.
    Secondly, the uninsured number is an advocate’s number. It counts as currently uninsured anybody who had as many as one day in the year without insurance even though that person today has insurance. It counts illegal immigrants, about eleven million, who would not be covered in any event and wouldn’t want to sign for it anyway absent an amnesty. It counts several millions with household incomes above $50k who could afford it but choose not to. And it does not account for young people whose view is that their primary risks are auto accidents and work-related problems, both already covered by auto and work comp. Their other woes are, for the most part, pretty small. Rashes, hay fever, sprained ankles and such. The unfortunates who guessed wrong are few and…don’t go and die by the side of the road anyway.
    I had a young dentist insured who insisted on a $2500 deductible. “saved” money. Tore up an Achilles tendon and had hell’s own time coming up with the deductible. The savings were gone. Some people, you just can’t make them think, no matter how smart they are.
    Point is, you need to be really, really sure of the connection between no health insurance and no access to health care. And you need to be really, really sure of the numbers of and reasons for those uninsured to be uninsured. Problem is, getting to an agreement on either of these presents fertile ground for obfuscators and BS artists. You’ll never get to a genuine discussion of the issues because–here’s the real point–they don’t want a real discussion of the issue.

18. “Might we not invent a new name to take into account the fact that they [are] forbidden to operate in the traditional manner of insurers, who cover people for future catastrophic events, and are allowed to take into consideration such basics as risk factors?”

    Or we could let them keep the name and decide to base the healthcare system of the greatest nation on Earth on something with better health outcomes that’s cheaper and isn’t a complete burden on small businesses and corporations.

    Your closing paragraph shows why there is no logical reason for insurance companies to provide the basis for general healthcare in this country. Their entire business model is based in paying out less than they are paid by their customers. Good for profit, but crappy for healthcare. They’re middlemen at best, and acting like healthcare is a market like any other is the root of our failed attempts at reform. Nobody has the option to shop around a brain tumor.

    We need basic universal coverage with supplemental insurance for those who want a higher level of care. THAT’S the role that insurance should play in our healthcare system. Then they can make whatever rules they want as they compete for customers (but good luck staying in business refusing pre-existing claims). And linking it to employers? Get employers out of the health game. The European and Asian countries who have done this are killing us in the global marketplace.

    Asking “why should I have to pay for someone else’s healthcare?” makes as much sense as asking “why should I have to pay for someone else’s US military?”. You already are. We might as well make it official.

19. Richard –

    Just to be clear, I’m aware of all of that – I was granting the uninsured number for the sake of argument (my point was that even IF the number was right, I would still think our system was more just than a single-payer system such as Britain’s and Canada’s). I could have been clearer that I was referring to the number arguendo.

    But you piqued my curiosity when you said “they don’t want a real discussion of the issue.” I think so too, but my thought was that the issue was one of a clash between two incompatible visions of what constitutes a good society. So when I asked that last question, I meant to put the hardest case to myself – grant that there really are 45 million (or whatever the number) “without insurance”… Would I still say that our system is preferable to single-payer systems, even if everyone really did have “insurance” there?

    My answer was (is) “yes,” and I suspect that many, probably most, conservatives would say “yes” as well, although not in public (understandably). Why? In brief, the law of unintended consequences.

    Likewise, I believe if the question were flipped and the progressive had to answer if he would prefer his single-payer vision even if the unwieldy, quasi-private system of America were orders of magnitude more efficient and innovative, he would say “absolutely.” Why? Basically, because government is morally obligated to redress injustice to the fullest of its capacities.

    Granted I can’t prove any of that; it’s just my hunch – that the obsessive intertextuality of our compulsive citing of OMB, CBO, Think Tank op-ed, academic, etc., analyses of raw efficiency, with morality merely the nebulous adumbration of the whole discussion, is precisely the converse of the actual situation. Our moral visions are guiding our preferences (I’m speaking generally, not for you or for Brad), and efficiency plays second fiddle.

    The issue, then, as I see it, is “What sort of a society is a good society?” I’m personally willing to live with a good deal of gruffness and vulgarity and imperfection if the people are mostly free and the central government does not engulf civil society. I’m being short, because I don’t want to write a treatise here, but that’s the gist of it. A leftist is far less willing to tolerate what I am, because he thinks a precondition for a free society is the central government controlling civil society and straining all of the gruffness, vulgarity, and imperfection out of it. In essence, a constrained versus an unconstrained vision.

    To give credit where it’s due, I’m borrowing a theme from Steven D. Smith’s recent book, “The Disenchantment of Secular Discourse”* – what he calls “smuggling,” as in: One who talks in value-neutral terms but assumes a morally loaded, but unstated, metaphysics, is “smuggling” morality into secular discourse.

    Is this what you had in mind? Or am I way off?

    (*Please anyone who sees this post, read Smith’s book – read all of them. He’s a neglected genius of philosophical jurisprudence, and I consider it my duty to proselytize on his behalf.)

20. kolnai
    If you ask yourself, what is one of the best ways to destroy our economy, put unaccountable ‘crats in charge of even more of our lives, turn more people into passive sheep, provide for a two-tier system (Congress isn’t going to be bothered by Obamacare themselves and the rich can always go to Costa Rica where the good docs will be setting up gold-plated clinics) that damages Americans’ sense of equality, would you choose government run health care, you might be getting close.
    Just because you’re paranoid doesn’t mean they’re not out to get you. I met people who thought the US needed an overhaul so huge that it would take a revolution. Which they wanted. Others wanted to do it piecemeal. That was before I’d heard of Cloward-Piven. I used to hang with lefties who thought, from time to time, I was on their side. Got on the in-group mailing lists (that was a blast).

21. Start with the premise that nobody is turned down “care”.

    Hospitals have eaten the cost of the un-insured – especially in areas near the border….

    Now add into the mix that health insurance is a business model designed to put into contract a way of providing payment for high cost or catastrophic care.

    Just like car insurance is there to protect you in case of a car accident – catastrophy.

    What has happened is that Americans now want to morph insurance from catastrophy to everyday costs like replacing a windshield or paying for each and every doctors visit when you have a cold.

    So yes – premiums will go up because we expect more out of the insurance company.

    Remember the first premise Brad.

    Remember the hypocratic oath is not part of this mix.

    …. 🙂 Unless liberals get their way – the hypocratic oath will be replaced with beaurocratic “death panels” to save the government money.

    Damn the contracts!!!!

22. Baklava: actually, I think many Americans would prefer catastrophic insurance if they realized the savings to them, and were allowed to purchase it instead.

23. I get your point.

    I was in the individual market for 7 years from 2002 – 2009 and I paid over $14,000 PER YEAR for 3 policies (me and my two daughters).

    And why?

    Because that’s what my ex-wife wanted. She wanted the coverage that paid for everything with the least co-pay per visit.

    But there were plans that would’ve cost me less than half that much (approx $6,000 per year) with decent coverage and only marginal co-pays – and one of my daughters had to have an underwriter for a HIPAA plan because she’s considered to have a pre-existing condition.

    Here’s the kicker.

    Do I have a big flat screen tv and an HD dish? No.

    I have a single 27″ tube in my house with non-hd 40 channel subscription.

    How many DVD players do I have? None. Only the one in my laptop.

    Do i have a smartphone? No.

    People make choices in life and they need to prioritize differently and take PERSONAL RESPONSIBILITY for their choices.

24. Baklava – Amen.

25. Baklava.
    You sound like a fascist hater.

26. Tom @8:10 pm :

    I’m used to some feeling free to call me names or call my character into question on here, as if those kind of things ever added to an argument. I’m glad you didn’t, but I was getting ready for it.

    I see a role for private insurance even if we went to a “public option” type system (single payer would actually ban private insurers) and yes, you are right that price competition would be a good thing. I don’t see it happening with Obama’s exchanges, which is why I’m skeptical the current legislation will solve much of anything.

27. kolnai at 9:18 –

    Very well -thought out post though you make some assumptions about my beliefs that are incorrect.

    For one, I do not think the British NHS is a very efficient public option style system. I only mentioned it because I think ultimately the best way to go is probably basic care for everyone covered by the government with private insurance being an option and a right (meaning you could not be forced into the government plan, nor should it be legal to ban private insurance as a main option or a supplement). I’ve always felt since about 2007 (done a lot of investigating this topic myself over the past 10 years) that a combination of the best aspects of the French system, the current US system, and possibly a few things from Germany is the way to go. I must also state that until about 4 years ago I did not think we “had” to do anything. Only years and years of seeing health care costs continue to rise, congress do nothing to rein in costs by reforming laws or allowing inter-state competition, or working to decouple health insurance from employment (COBRA, honestly, is a bad joke, and we are in a global market with an extremely unstable job market right now) convinced me that the current system will collapse on its own regardless of what various demagogues on all sides of this issue think.

    I’m aware of far more nuances in this debate than you think. You might consider that I had a Reason subscription for 4 years in the middle part of last decade, that I was a weird kid who read the National Review when I was 10, etc. There’s no doubt that the US system is abominable in some ways , particularly in terms of cost for benefits delivered, but it’s the best of the world in terms of quality of care delivered for most diseases, that it often sucks at palliative pain treatments, that it totally rocks in terms of medical research conducted (though this isn’t including drug and vaccine research where it, once gain, due to FDA and greed and all sorts of things once again sucks) and etc. I know that the reason that our “infant mortality” rate is high is because we include preemie babies that most other systems don’t even try to save.

    There are two main problems with US healthcare as currently conducted that will bring about the end of the system if they are not addressed: Cost and coverage. Both “liberals” and “conservatives” have to offer their ideas because the default will be collapse and then whoever is ready with a plan or solution first will be the ones that desperate people turn to.

28. brad.
    You mix up health care costs and insurance premiums again. How does interstate competition reduce the rates the local cardiologist charges? See?
    Now, I may not have been a weird kid, but I did sell health insurance. I know that disqualifies me as opposed to youthful reader of Reason, but I’ll soldier on anyway.
    Most companies have intrastate competition. In large urban areas where docs charge more, the companies pay more (usual and customary for the area) so the companies charge more because they’ll be paying out more…than in the up/down state rural regions where the difference in premium could be thirty percent. So crossing state lines would be useful because…?
    Many companies sell in several states. How does crossing state lines actually work when the companies already do it? I mean, I could live in Milwaukee and buy a contract suited for Detroit, but why? Or I could live in, say, Cadillac, MI and buy a contract priced for Chicago. Bad idea. Cost too much. Or I could live in Chicago and claim I lived in Cadillac, leading the company to think they’d be paying out half the usual&customary to the docs and get the lower premium.
    The problem with prices for medical care is that the companies with their minimal deductible contracts and low total out-of-pocket costs have divorced the consumer from the prices of the services. If you and your neighbor, the one with pancreatic cancer, pay the same premiums and you pay nothing to the docs because you’re healthy and your neighbor pays a couple of thou, it doesn’t matter to either of you what the doc is charging the insurance company.
    Prior to WW II, docs were respected members of the upper middle class. During WW II, with wage controls, companies competed for labor with benefits, whose premiums were deductible to the employer and not taxable to the employee. If you give a guy a raise of $100, something like $12 is going to SS, $25-$35 to the IRS, possibly something to the state and local government, and the employer may have to pay more in work comp and unemployment insurance premiums. Put the same toward the health insurance and all the parasitical expenses disappear and he gets a reduction in his deductible of something or other, which strikes him as particularly neato when he has that in mind, i.e. when he or somebody in his family is sick.
    Now, I’ve left a trap in here. Don’t anybody fall into it.
    Anyway, high deductible plans which will keep you from being bankrupted in case of trouble would keep premiums down and put downward pressure on the front-end stuff. You go to a urologist who does a bladder scan, a urine test, does the finger thing and tells you he’s at a loss for the symptoms. That’s $190, please. Not a problem. My insurance pays for it. What, you mean I have to pay for this nonsense? You cannot be serious!!!!

29. Richard:

    I don’t understand how someone who worked in the health insurance industry thinks you can de-couple the the costs of insurance and healthcare and doesn’t understand that there are different health insurance regulations as to what has to be covered in different states. The differing regulations (and hence differing cost of “basic” insurance coverage over and above other factors like age demographics per state) are way places like CATO tend to want insurance to be purchasable over state lines. They figure this will spur price competition and also intra-state competition on price and quality.

30. Er, I meant “Inter-state” competition.

31. Good grief…you people are so full of shit.

HTML tags allowed in your comment: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>