ponderings: health care

[cellio]

In the comments here we were talking about health care in the US. The current system is broken in many ways, but the "nuke it and start over with some nationalized program" proposals are scary too. What incremental improvements are possible? I have to believe that there are some.

One idea I'm interested in is what would happen if we separated paying for routine care from paying for catastrophic care. What would happen if people could be on their own for the former but could buy a policy to cover hospitalizations, major illnesses, and the like? How effective would that be and what would it tend to cost? What would having that in play do to the over-the-counter (uninsured) price of routine care? (Yes, I know that not everyone can afford to pay for routine care out of pocket. I'm exploring a suite of options, not choosing a single one.)

On the flip side, would medical practices or insurance companies be willing to sell affordable plans that cover all your routine care (only), if they were not on the hook for catastrophic losses? Could that get things down to the point where the average family could afford regular checkups, preventative care, and routine tests (which helps prevent some catastrophic issues)? Such plans exist now in niches (vision and dental, most commonly in my experience), but I haven't heard of one for general medical care. Why not? (Am I totally misunderstanding where the profit centers are in the insurance business?)

Both angles are important. What I'm labelling catastrophic incidents are (as the label implies) financially devastating if you don't have sufficient coverage. Outside of elder-care issues I'm not sure how common they are, but it's the sort of thing I wouldn't want to take a chance on. I insure my car and house, after all -- how much the moreso should I insure my health?

What I suspect has a bigger impact on the poor, though, is the routine care. If you don't have insurance, you're looking at a three-digit number to walk into your doctor's office. Throw in some kids and you're in trouble. (This is why I asked what would happen to those costs if catastrophic care were a separate factor.) Could plans that just cover routine care be made affordable enough for most people? This doesn't solve the other problem, but neither does the current system -- we rely on hospitals' obligations to treat (which is a legitimate public demand while they pay no taxes), or medicaid/medicare/SSI in some cases, to get through those. Remember, incremental improvement.

I'd also like to explore the effects of reducing drug regulation, letting people buy from anywhere that's selling and reducing barriers to getting things onto the market. I know the standard argument against this (those high prices pay for R&D), but I'm not sure how much I believe that. What are the other considerations?

Where else could we look for incremental improvements?

(In case you haven't figured it out, I am not a medical professional, an economist, nor part of the insurance industry.)

Comments

[byronhaverford.livejournal.com]

Aaaaah! Way too much! I really did want a different forum (e.g. face-to-face) rather than a new thread. LJ threads are too disorganized to construct a single coherent argument.

I will say this: You are too optimistic about people buying insurance when it is not mandatory. /You/ would buy it, but a large fraction of the population would not. There is a reason that car insurance is mandatory.

I would say that about 50% of the information in this thread is accurate. (I'm of course talking about the 50% in /your/ thread, whoever you are.)

[cellio]

I really did want a different forum (e.g. face-to-face)

Understood, and I do want to have that conversation when we're both available. (Last night was not the time. :-) ) Meanwhile, I also want to discuss it with folks I won't have that chance with. It's all good.

I will say this: You are too optimistic about people buying insurance when it is not mandatory. /You/ would buy it, but a large fraction of the population would not. There is a reason that car insurance is mandatory.

A part of me has very little sympathy for people who can buy this protection and choose not to. Note that I am not including in this group people who have difficulty paying for it; I'm talking about the careless, who can and decline to. When the 25-year-old making six figures who won't buy insurance wraps his Miata around a telephone pole, my gut reaction is "tough noogies". As a compassionate human being I would of course have great difficulty actually letting such people die or suffer terribly from these self-inflicted wounds, but as someone mindful of justice and fairness I wouldn't have a problem with limiting their care to the essential. Neither "all compassion" nor "all justice" makes for good public policy; the challenge is to find the balance point. You probably have an interesting take on this, which I'd like to hear in a forum where you're comfortable sharing it.

[byronhaverford.livejournal.com]

>A part of me has very little sympathy for people who can buy this protection and choose not to.

Oh, me, too. But what are you to do with him when he shows up in the emergency department? There's no time to ask whether his premiums are up to date. And what are you going to do with him the next morning when you discover that he's uninsured? Kick him out on the street and take back the protective collar you put on his neck? There are practicalities that limit the compassion vs. justice debate, mostly in favor of compassion.

[cellio]

Agreed. I wasn't trying to articulate a policy, but rather explain a feeling that can't help but guide my thinking. The person willfully without insurance is like any other deadbeat; he incurs debt that you may never recover, and society ends up being on the hook for some of it. There might be things you can sometimes do (they garnish the wages of deadbeat parents, for instance), but it's very hit-or-miss.

The differences with the ER case wouldn't come in the initial care (you stabalize and fix the big stuff regardless), but I could see differences in the after-care. For example, if a bone doesn't set quite right but it's not a major impediment, he would be out of luck while someone with insurance could get the corrective surgery. Ditto on the plastic surgery to deal with ugly scars. I don't know how much variation there really is on stuff like this. And, as I said, I don't have a solution -- just thinking/wondering out loud.

[byronhaverford.livejournal.com]

Do you have a philosophical disagreement with mandatory car insurance?

[cellio]

Mandatory liability coverage? No, because your auto accident can cause damage to others. Actually, so can your non-driving activities, so if going down this path we should mandate umbrella liability coverage instead, so you can pay for the damage you cause in any context. (A practical consideration, though: we should be mindful of mandating use of an industry's services while allowing them to set the conditions; most people can't afford to self-insure to any reasonable level.)

I don't think you should be compelled to cover your own damage if you don't want to. If you don't want to insure against property damage to your fully-owned car, house, expensive equipment, etc, that's your problem. I see your body as in this same category.