That seems to be the state of affairs in most of the US. Either your have generous parents with lots of money, or you graduate medical school with huge amounts of debt that can push you to chase the money in career and life decisions. Maybe somewhat less debt if you are a Texas resident (where the in-state public medical schools are relatively inexpensive).
If you want to have universal coverage with guaranteed issue, the simplest options would be:
a. Medicare (with Medicare Advantage private option) for all. (single payer with private option)
b. Government employees health care benefits extended to all. (vouchers)
In either case, it can replace the various other government health care programs as well, and unlink health care from employment status. However, either would require restructuring some of the taxes, as well as a net increase in taxes somewhere to pay for the extension of coverage to those currently uncovered. Of course, this would be fiercely lobbied and contested, particularly by those whom any added taxes would be applied to.
Bringing cost down would be a very difficult political process, since there is no one big added cost that can be cut. Each added cost individually is a small one, defended by a powerful special interest (drug companies, physicians, hospitals, lawyers, medical schools, etc.), so bringing costs down would mean fighting political battles on many fronts.
It has to be done, though. Decisions have to be made. Every year, we invent new technologies, new drugs, new treatment regimens. Every year, medical costs go up faster than the rate of inflation. If we do nothing, Medicare and Medicaid will eat up the entire budget. We have to bite the bullet and stop paying for things that are not cost-effective. You may want the $150,000 cancer treatment that will lengthen your life a week if you’re lucky, but the rest of us can’t afford to pay for things like that. Some will squeal, “Rationing! Death panels!” but we don’t have an infinite amount of money to afford an infinite amount of health care. At some point, we have to set limits. We should start right now, by stopping paying for treatments that don’t work at all.
There are a lot of quasi-hidden benefits to the ACA that many people don’t know about or don’t give much thought to.
Catahoula defends physicians getting $400K+. So let me ask a question: why does a doctor get paid more when you are sick and keep having to go back to him/her? I got sick and the doctor kept failing to prescribe the correct medicine. I kept having to pay co-pays. The worse the doctor performed, the more visits he got paid for. Does that make sense? The ACA addressed this.
A significant feature of the ACA was creating a legal environment leading to Accountable Care Organizations, which is a structure where multiple providers band together to communicate with each other and provide team-based care to patients and get bonused based on good patient outcomes, not number of visits or procedures. The ACO’s have shown some real improvements in quality of care.
Many doctors hate the ERMs, but they have been another huge contributor to improved medical outcomes.
The ACA was essentially an insurance change, but there were so many other great things that were either in the bill or which resulted from the bill. It saddens me when politics interferes with patients’ lives.
I love ERMs (electronic medical records) but they have not AFAIK been shown to improve patient outcomes.
There’s a bit of research so far on ACOs (Accountable Care Organizations) which showed a cost savings of 1.2% over a year, which would be good, but a study that only lasted a year has to be regarded as preliminary. http://www.nejm.org/doi/full/10.1056/NEJMsa1414929?query=featured_home
The article you linked refers to a study that lasted a year but the article itself is 18 months old. There is more recent data on both fronts.
This more recent study from the same authors has worse results:
http://www.nejm.org/doi/full/10.1056/NEJMsa1600142
Other recent studies?
@“Cardinal Fang” re the $150k cancer treatment that adds a week to your life… the issue is you just don’t know how an individual will react to a particular treatment (yeah I know that’s common knowledge but it’s so true). My oncologist thought the chemo I’m currently on would work for a few months and was intended as a stop gap while we evaluated other options. Well it’s bought me 15 months at this point, surprise surprise. Guess we could ask how much is it worth to use a drug that you think will extend life say a year. I can see asking that question (with all the requisite caveats) but not sure how you answer it from either side of the coin
These are the type of tough questions we need to deal with in order to have a universal system of coverage.
806. I'll have to PM you.
“Good patient outcomes” sounds good but often depends on the patient’s compliance with doctor’s orders. If the patient doesn’t take the medication as prescribed or doesn’t follow the guidelines for taking the medication that’s not within the doctor’s control Doctors will drop these patients. This will affect those at the margins of society the most.
JustGraduate, glad to hear you are doing well. I’m on one of those $100k/year drugs that has bought me extra years. I wrestle with the ethics of it a lot, but have kinda made peace with it by using this bonus time to do whatever I can to make my corner of the world a better place. Wishing you continued good health and energy to spend time on the things that matter to you.
I understand what CF is saying and I agree with her. Our end of life care costs are out of control.
With that said, I’m also on a 100k/year drug that takes 6 months to figure out whether or not it’s working. If it does, I’ll be on it for years until it stops working and then I’ll switch over to another (probably more expensive) drug. I have a complicated overlap of diseases and there really isn’t research showing whether or not that particular treatment would or wouldn’t be effective in me.
I don’t pretend to know what the answer is, but it is something we need to have a serious and non-hysterical conversation about.
The hard part of this is that individual variation can mean that some treatments are useless (or worse) for most, but useful for some. So, while a blanket approval to pay for such treatments can lead to wasteful overtreatment, a blanket disapproval can lead to those who would benefit being denied.
Note that this is not just end-of-life care. Consider mammograms for breast cancer screening for women age 40-49, for example.
801
"…If you want to have universal coverage with guaranteed issue, the simplest options would be:
a. Medicare (with Medicare Advantage private option) for all. (single payer with private option)
b. Government employees health care benefits extended to all. (vouchers)…"
Do either of the above options allow the current health insurance companies to stay in business?
Interesting look…
In contrast to exchange plans…
Wow…so in response to something not working, to an obvious problem with what is being offered…two States (so far) decide that the solution is to remove the desired product and only offer the undesired/subpar product. How dumb.
Where are these off-exchange plans? In my area, I see the same plans on HealthCare.gov as I do on the BCBS site (the only participating provider in my county). At eHealthInsurance, again, only BCBS plans pull up, unless I look at short-term (interim) plans, and then there are more companies to choose from. An interim plan won’t keep you from paying the penalty will it?
Yep…for ACA 2017, my one kid had only ONE vendor choice…basically meaning it was not a “choice” but rather the selection that had to be made.
Upstream, @ucbalumnus said he found a bunch of primary car providers who “take” the plan. Maybe that is what is on the list of providers…but in reality,it’s not what is said on the other end of the phone when you call and say you are a new patient. Maybe those many providers who accept the one plan do so for patients they already have. That does NOTHING to help those who are looking for a new primary car provider…nothing.
I read an article in today’s New York Times Magazine (12/11) about people stuck in ACA’s “Dead Zone”, which is defined as people that don’t have enough income to qualify for ACA subsidies and live in states that did not expand Medicaid. I found the article online and it was published 5 days ago (!) so I don’t know if it has been cited in this thread yet. I mentioned earlier that my wife and I are supporting a local free health clinic (we live in NC) whose clintele are people that have no insurance and exist in this ACA “dead zone”.
http://www.nytimes.com/2016/12/06/magazine/life-in-obamacares-dead-zone.html
@dietz199 , that article on off exchange plans is appropriately headed, “Commentary”. I found this article which explains the difference (and existence) of off exchange vs on exchange plans (some are the same) and it also states that Vermont now allows off exchange plans, so only Washington D.C. does not permit it.
https://www.healthinsurance.org/obamacare/off-exchange-plans/
Yep. It sounds like your kid is in a particularly bad market. The only saving grace for us is that our PCP (primary care physician) in our HMO is energetic and competent. However, the couple of referrals we’ve had from him? So, so, so disappointing.
For our one kid, we went out of network & paid full freight, for a skilled therapist and psychiatrist. Neither practitioner accepts any insurance at all, although they will give you a statement to submit to your insurance provider (not applicable in our case). The quality of the initial referrals were very poor.
I was referred to a dermatologist, and again, I was so disappointed in the quality of care. And the co-pay for the short, crappy office visit was $100. I didn’t follow up.
It makes me nervous to think of what would happen if any of us had a serious medical condition.
Quality for the price is my issue. Illinois has had substantial rate increases this year.