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<p>It’s akin to the “skin in the game” argument. There is no incentive for people to care about the costs of health care or how they use it when they are insured by these cadillac plans with very low deductibles that cover very expensive care with no questions asked. The idea is to make these plans less attractive since it is argued they may encourage overuse of medical care. They want more value-conscious consumers.</p>
<p>^ That is the part that is baffling. They have no profit, they are collecting taxes from all of us and then they have to give part of it to Feds? If they were doing anything, it should go to support the local Medicaid or something.</p>
<p>Yeah thanks jym, we are fine. They haven’t released the names of the pilots, don’t know if I want to see them, as I know a number of people there. UPS has highly trained pilots, and the A300 is a good airplane, so I can’t even speculate on this one. But early in the morning, fatigue is always a factor.</p>
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<p>Busdriver, when a company passes on the costs of their higher tax or higher costs to their customers – as they do – that cost becomes very diluted. I remember at one point the owner of a pizza chain said that the cost of insuring all the employees would translate into an extra 14 cents per pizza - and they were planning to tack on 20 cents to cover that charge. (Charging 20 cents to pay 14 cents looks like “profit” too me for a large volume company)… In any case, as a consumer, I am perfectly willing to pay 20 cents more on every pizza I ever buy so that all of the people with pizza-making and pizza-delivery jobs can have health care. I can afford the 20 cents. I probably won’t even notice the 20 cents, because I have always given tips to pizza deliverers on my door step, and I generally simply rounded up – so if the pizza cost $12.38 the guy at the door got $15, and if the pizza costs $12.58 the guy at the door will still get $15 – so I guess in a sense that the 20 cents might be coming out of his tip … but he’s the one getting teh health care, right? </p>
<p>(Actually I don’t order pizza any more, as it isn’t really good for my health to eat food consisting primarily of carbohydrates and fats … but if the restaurant adds the 20 cents to the cost of a salad instead, I’m still happy to pay.)</p>
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I believe that is actually the point of the law, but the politics stood in the way of them passing that. That’s really the big problem with a lot of ACA provisions – they can’t call a tax a tax and get enough votes in Congress, so they start burying their taxes and calling them something else, or else try to make the tax (or penalty or surcharge or whatever they call it) look more acceptable by making it appear that it is directed only at the other guy (rich people or smokers or some other group that doesn’t arouse a lot of sympathy as a constituency). (Note, my comment is not intended to be expressing a political opinion, but rather a neutral observation based on the political process).</p>
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<p>This is an important point, and many healthcare economists agree with you, kmcmom13. Some even argue people shouldn’t have health insurance for routine care, they should just have catastrophic or major medical coverage against the kinds of health care costs that can drive people into bankruptcy—and that many health insurance plans won’t pay for. The argument is that by insuring for routine medical care, we distort demand for health care, creating an incentive for people to overconsume. People figure they (or their employers) have already paid for the care through their health insurance premiums, so why not get something for it? And the out-of-pocket costs (co-pays and such) are typically just a small fraction of the cost of the case that people don’t make rational cost-benefit calculations at that point. (I’m not sure I buy that line of argument, but it’s out there). </p>
<p>But the irony is that many people, often without knowing it, have just the opposite. Their health insurance insures against everything BUT catastrophic medical costs, because of the built-in lifetime caps, annual caps, and sometimes incident caps (so that, e.g., even if you don’t run up against your lifetime cap, you might be limited to $20,000 per surgery so you’re stuck of that complicated heart surgery costs $50,000).</p>
<p>Think about your house. Chances are you don’t insure against routine maintenance and repairs or even the need for major renovations. You do insure against catastrophes, like the house burning down or being destroyed by a tornado. Many health insurance policies are analogous to homeowner’s insurance that covers routine maintenance and repairs, but doesn’t provide coverage against total destruction of your house. The ACA is trying to put an end to that by eliminating annual and lifetime caps.</p>
<p>Bclintonk, I agree with you in theory, for myself: that is, I would be very happy to pay a moderate premium for a straight high-deductible policy that paid absolutely nothing until I hit my deductible, and then paid 100% of everything. In fact, my current HSA was structured very much like that; ACA compliance means that they’ve added in more preventive care, but if I do the math it’s probably not worth the extra premium cost.</p>
<p>But as a societal, policy issue – that’s not good enough. There are too many people who couldn’t afford the cost of basic care (preventive care and the type of routine visits you might make when the baby is fussy and tugging at his ear, or you’ve got a nagging cough that doesn’t seem to be getting better)-- and a deductible set too high might cause them to defer urgent care as well. Most preventive care is, in hindsight, unnecessary – that is, people who don’t have cancer will not be hurt when they don’t get mammograms or colonoscopies. But the flip side is that there are huge societal costs for the small percentage of patients who have a serious condition that could have been prevented with routine preventive care: premature babies with a lifetime of health care costs who would have been carried to term, if only their moms had received prenatal care – and late stage metastatic cancers that could have been nipped in the bud, if only the patient had received the recommended screening. </p>
<p>So we need a system that reaches all the people who can’t easily afford that routine stuff.</p>
<p>Additionally, if our system is built around requiring people to pay a monthly premium, it will work much better for most people if they perceive that they are getting something in return. Obviously, if you do the math, the actual out-of-pocket cost for routine care for a healthy person is probably far less than the cost of a year’s worth of premiums – but that’s ignores the psychological aspect. </p>
<p>I can think of a system that would do a better job of separating out these two very different needs – in fact, I can think of more than one – but that’s not what ended up getting passed, and my ideas probably wouldn’t stand much of a chance of passage.</p>
<p>Moreover, the ideas bclintonk expressed are fine for people who are basically healthy. But some people were unlucky in the lottery: they were born with, or developed, continuing conditions that keep costing money.</p>
<p>I too have read health-care economists who advocate high deductibles. But the ones I’ve read don’t advocate high deductibles for everyone. People of very modest means with serious chronic conditions should not have high deductibles; they must be vigilant about their regular visits to health care providers, and anything that would tend to keep them away (like fees) should be avoided. Blindness and foot amputations are the predictable, inevitable result of putting barriers in the way of low-income diabetics getting regular health care.</p>
<p>So, for me, a high deductible would be OK. I probably should think twice about going to the doctor for every little thing. But a diabetic should not be thinking twice, or even once, about skipping doctor visits.</p>
<p>Moreover, how does catastrophic health insurance work for expensive chronic conditions? Does the couple with the daughter with cystic fibrosis get to pay the $50K deductible every year, before insurance kicks in?</p>
<p>High deductibles are fine for healthy people, but not so fine for people with chronic conditions.</p>
<p>^^ They’re also pretty fine for the health insurance industry.</p>
<p>Yes, for folks with low to moderate incomes and chronic health conditions, skipping meds can often just mean much higher med expenses due to ER and hospitalizations and worse. With COPD (emphysema and chronic bronchitis), delaying a DOC visit can mean an expensive prolonged hospitalization, rehabilitation and permanent loss of lung function. </p>
<p>As was said, in diabetics and those with other chronic health conditions, there can be many permanent and awful consequences for delaying or not having prompt and regular medical attention.</p>
<p>Also, remember the big costs are concentrated in a small percentage of the population . Eighty percent of US health care costs go to treat 20% of the population, and in a given year, half the population has essentially zero health care costs. </p>
<p>In 2009, a quarter of all health spending went to treat 1% of people, who each had medical costs of over $50K that year. </p>
<p>High deductibles are not going to make as much difference as you might think, because they only affect people who think they would not reach the deductible. If you are among the 50% who have no health care costs in a particular year, high deductibles are irrelevant to you. If you are among the 10% who will spend over $10K on health care in a particular year, a $10K deductible will be irrelevant to you. So only about 40% of the population, and only about 35% of health care spending, would be directly affected by high deductibles if everyone had them.</p>
<p><a href=“http://kaiserfamilyfoundation.files.■■■■■■■■■■■■■/2013/01/7670-03.pdf[/url]”>http://kaiserfamilyfoundation.files.■■■■■■■■■■■■■/2013/01/7670-03.pdf</a></p>
<p>(Aside to jym26 – not pineal, unfortunately, but colloidal at 3rd ventricle and >1.5 cm … Treatment approaches are controversial…generally asymptomatic but suspect migraines relate to csf…but thanks for asking. It makes healthcare coverage a germane issue for us though we feel blessed his continued good health.)</p>
<p>On topic, we looked at high deductible plans which would have suited us fine – we were really only concerned with catastrophic events. But then we looked at employee conduct (not including me) over simple things like managing a copay in a single salary household with a SAHM and several children, and realized that because we’re so small and can only offer one plan it was better for employees that were high toll healthcare users and not great savers to have something teetering on Cadillac. That year our lead designer’s wife was pregnant and we still witnessed financial strain even though we pay 70% of his family plan and went with the lowest possible copay and smallest annual out of pocket limit. </p>
<p>Some folks are not inclined or able to maintain adequate reserves for medical expenses it would seem. It’s possible the employee in question might prefer cash to the coverage, but I’m not optimistic his family would receive adequate care had we done that. We will see in 2014 what happens in this case, and whether its time to tweak the approach.</p>
<p>Here’s an article about one way we can get more primary care providers to treat the newly-insured patients from Obamacare.</p>
<p>Nurse practitioners trying to get right to practice autonomously, doctors oppose it:</p>
<p>[Nurse</a> Practitioners Seek Right to Treat Patients on Their Own - WSJ.com](<a href=“Nurse Practitioners Seek Right to Treat Patients on Their Own - WSJ”>Nurse Practitioners Seek Right to Treat Patients on Their Own - WSJ)</p>
<p>The article tells us the California Medical Association, representing 37,000 doctors, opposes NPs practicing alone. That should not be taken as the position of all doctors, however. There are 95,000 practicing physicians in California, which means that the large majority do not belong to the California Medical Association.</p>
<p>My mom lives in a very rural area where there is a shortage of doctors. She’s 88 years old and hasn’t seen her cardiologist or orthopedic doctor in years. She can only get appts with nurse practitioners. Even if she insists on seeing the doctors, they aren’t familiar with her history at all so it’s a waste of time.</p>
<p>The ACA has some pilot programs that pay by diagnosis, rather than by service, to incentivize hospitals and doctor groups to coordinate care. </p>
<p>I’ve been frustrated that my mother doesn’t have one medical professional that is in charge of all her care, and that seems to be true of a lot of older seniors who have several different medical conditions. If Mom could see a nurse practitioner (or somebody) to coordinate her care, she’d be better off. </p>
<p>This is even true-er for people with terminal conditions: so often, we hear of a senior getting some surgical or other treatment that might be indicated for one particular condition, but that is ridiculous for someone in the state of health that the patient was in. I wish there was a care provider who would be saying, “Wait a minute! Why are you doing that surgery on someone who only has six months to live? Should they spend two months of the six months recovering from this surgery, or should you instead be offering aggressive palliative care?” I wish there was someone in charge of the whole patient.</p>
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<p>My parents are in that 1%. I know that not all high-cost individuals are seniors, but I would think that the lion’s share are. My father alone has probably had a million dollars’ worth of care in the last 3 or 4 years, and my mother isn’t far behind. As a taxpayer – and yes, even as a daughter – I sometimes have to question the value of all that spending. Dad is 86 years old and has heart disease, kidney disease, dementia, and a broken ankle, among other things. And yet in a few weeks, he’s going to have surgery for bladder cancer which will cost, what, $15K? $30K? $50K? From a cost standpoint, from a quality of life standpoint, from a common sense standpoint, it makes no sense at all. But no one, either on the medical team or in the family, has dared even whisper the idea that maybe it shouldn’t be done (except me, safe here in the anonymity of CC). </p>
<p>There was a startling chart earlier in the thread comparing US healthcare costs, by age, with other developed countries. Our spending is not that out of whack with everyone else’s until you get into age 60 or so, and it diverges more and more sharply as age goes up. Based just on that chart, you’d expect that Americans would live far longer, and have a far healthier old age, than anyone else. But of course, we lag behind on many health indicators. </p>
<p>I wonder why. How is it that so many other countries manage to keep their seniors living longer than ours, and having healthier old ages, at a dramatically lower cost? Unlike us, they have discovered that they don’t have to choose between taking good care of their seniors and breaking the bank. What’s the secret that everyone except us has figured out?</p>
<p>LasMa, I wonder if you should try talking to your dad’s doctors. Even disregarding the cost of your father’s surgery, will it improve the quality of his life? Sounds like there is reason to question that. How well will a man with dementia and heart disease recover from surgery? Whose idea was this surgery, and do the other doctors agree? Can you or a sibling go with your father to an appointment, or talk to the care providers? </p>
<p>From what you say, this surgery sounds so bad. And who will be taking care of your dad as he is recovering? Will he ever get out of bed after the surgery?</p>
<p>Fang, he’s currently in skilled nursing anyway because of the broken ankle, and probably will be for a couple of months at least. So post-surgical care wouldn’t be a big additional burden for us or for the taxpayers. He has caregivers when he gets out, but he’ll probably never walk again because I doubt that he can be rehab-ed sufficiently even after the ankle has healed.</p>
<p>I have talked to his doctors, but not about this question. I guess I’m a coward. I don’t want to be the first one to suggest, either to his doctors or to my brothers, that we let him die of cancer. Even if, in my secret heart, I think it might be best for him and everyone else.</p>
<p>Interesting piece in the NYT on why medical costs are so high. </p>
<p><a href=“http://opinionator.blogs.nytimes.com/2013/08/13/the-cure-for-the-1000-toothbrush/[/url]”>http://opinionator.blogs.nytimes.com/2013/08/13/the-cure-for-the-1000-toothbrush/</a></p>
<p>LasMa, I think it would be reasonable to ask his doctors (not just the surgeon, but the other doctors who treat his heart and his kidneys) whether this surgery is in fact going to prolong his life, and if it is, what will the quality of life be with the surgery versus without it? What are the additional risks to him if he has the surgery, given that he has heart disease and kidney disease, compared to his not having the surgery?</p>
<p>There may be other options between surgery and doing nothing. Moreover, his health status may be such that the surgery wouldn’t, on average, prolong his life. </p>
<p>Surgeons want to do surgery, and will recommend it. That doesn’t mean patients (or their families) should agree to the surgery.</p>
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I don’t know, but I’m wondering if they do a better job of leveraging those senior-care dollars by concentrating them on the seniors who are most likely to benefit. I mean, your dad is a case in point: how much time is that bladder surgery going to buy him? what will his quality of life be post-surgery? No one in this country wants to be the one to make the decision to deny surgery that probably is clearly indicated for the specific diagnosis – but I wonder if in some of those other countries have different standards as to when surgery will be approved, perhaps focusing more resources on the individuals who are most likely to experience an extended and improved quality of life. </p>
<p>LesMa, I am sorry that you are going through this with your father. We have a similar situation going on in my family. I know that you must feel very torn.</p>