<p>Remember the argument against selling insurance across state lines: there would be a race to the bottom. I see the same thing happening here. Insurers in an attempt to lower premiums in the face of rising healthcare costs will keep narrowing the networks or degrading the quality of medical care for everyone by forcing providers to accept punishing reimbursement rates. </p>
<p>In your eagerness to provide universal access at a low cost, you just may end up killing the golden goose. It all sounds good until you get cancer or some other devastating disease, and the best care from the best facility is unavailable to you and your loved ones. It’s all good until it isn’t.</p>
<p>"The report shows that a 27-year-old Houstonian without a tax credit could pay $138 per month for the lowest-cost bronze plan. A family of four with a tax credit could pay $52 per month for the lowest-cost bronze plan.</p>
<p>Neither Cohen nor Sebelius explained how they would overcome such cost disparities and convince young people they need health insurance. Sebelius said the marketplace will offer many the chance to buy insurance. Six out of 10 people will pay less than $100 for coverage, she said."</p>
<p>This is the interesting part. I keep hearing all young people WANT to join insurance but I keep wondering about what their incentive is.</p>
<p>Unfortunately, a lot of people get cancer. And most of them don’t get treated at a super-expensive research hospital: they get treated at regular hospitals, by hardworking, smart doctors and other care providers. And that is fine with me. </p>
<p>Goldenpooch, you may want to get your cancer care from the most expensive oncologist in the world, but the rest of us are happy to say that we are providing regular normal oncologists to people buying health insurance on the exchanges. If nobody on the exchanges can get cancer care or heart surgery at Cedars Sinai, I’m not going to shed one tear.</p>
<p>Other than a marketing campaign. The earlier article said California was spending $97 million on its rollout which is like $4K per sub. And those are probably the money losing subs based on the number of beneficiaries. </p>
<p>I wonder if we will ever see the demographic breakdown on the subscribers?</p>
<p>But if they are not insured today, they have no incentive tomorrow to spend the money and do it (I am only looking at full pay). </p>
<p>I would be surprised if it costs them any more to be insured TODAY if they wanted to have coverage unless they fall under the precondition group.</p>
<p>That is why young people better get insurance. And the costs in Texas look good. There are going to be people on the ground in Texas pushing young people to buy insurance.</p>
<p>dstark, no, but I have numerous friends who were very sick and received expensive care from great teaching hospitals like Cedars or UCLA. I don’t think the local community hospital was the best choice for them.</p>
<p>“Exactly the kind of low-hanging fruit I was talking about. If we eliminate that surgery, nobody is worse off except the heart surgeons.”</p>
<p>Are you saying that that surgery should be denied even if the family or the patient requests it? What would be interesting would be if you could only get it if you could pay for it. </p>
<p>dstark, the doctors didn’t involve your relative or family in the decision about the stent? That doesn’t seem to happen in my family. I can think of several times I have been asked what “we” would like done. </p>
<p>Did he have an “end of life” thing on record? I can’t remember the name of it, but I am now required to have one when each child I treat turns 18. This is at “the county” agency.</p>
<p>Cardinal Fang, I hope you are never told by your primary physician you need care from one of those expensive facilities, although it would be interesting to see what your position is under those circumstances.</p>
<p>we can calculate (it requires some arithmetic) that there are about 18.5 million adults aged 18-34 that do not have health insurance, and of them, 17.2 have family income of less than 400% of the poverty line. So we’re talking about a group of some 1.3 million people uninsured and earning more than 400% of the poverty line.</p>
<p>I’m saying that the insurance shouldn’t pay for it if it is futile, even if the family requests it. And in dstark’s case, I doubt that the family was rushing to the doctors saying “Put in four stents!” The surgery was done, I am sure, at the instigation of the doctors, not the family. </p>
<p>The surgeons said, “We can treat your uncle by putting in four stents,” and the family said, um, yeah, ok, I guess that’s what needs to be done if you say so, doc. But if the palliative care doc had said, “We could put in four stents, but it wouldn’t work, and the insurance won’t pay for futile care. Do you want us to do it?” then the family would say, no, we don’t want futile operations.</p>
<p>I’m guessing “futile” could be calculated with regard to odds of “success”. In evidenced based medicine, they call it “number needed to treat”. </p>
<p>For the record, it is not that I disagree, it’s just that it can be very difficult to make that call. I think this is especially true in psychiatry. Do people REALLY want to know?</p>
<p>Ha lerkin! I was going to say the same thing but I exercised some self-restraint!</p>
<p>But what I was thinking was what about second opinions? That’s a decision that should rarely be made on the basis of one opinion. Does the insurance get to break the tie? Some bureaucrat? A panel of disinterested doctors at the hospital?</p>
<p>Don’t insurance companies already make that call? They deny treatments because of inefficacy all the time. And I wish they’d be more aggressive, and start denying more of those stupid stents which are known to be useless.</p>
<p>“I would say it should be the doctor who guides family decision.”</p>
<p>I hope we don’t go back to the doctors as the enemy; “gate keeping” and withholding “the goods”. I can’t tell you how many families seriously seem to think I have some vested interest in not telling them the truth about the treatment they are requesting. That doesn’t happen NEARLY as much right now as it did 10 years ago.</p>
<p>The trouble with doctors making the call is that the doctor’s incentive is not always the patient’s incentive. Surgeons have a bad habit of wanting to operate to fix one little thing when the rest of the body is failing. </p>
<p>And the patient’s incentive, alas, is not always the cost-sensitive option. Would I want the million-dollar treatment if it was 5% better than the hundred-dollar treatment? Well, yeah, if I didn’t have to pay for it. As a doctor, would I offer the million-dollar treatment if it was 5% better than the hundred-dollar treatment? I might; after all, it is better, and I don’t have to pay for it. </p>
<p>Some beancounter has to stand there and say, “Look, this isn’t worth the money. Stop.”</p>