Why people are afraid of universal health care

[T.G.G. Moogly]

In my area, more and more health care systems are declining patients with Medicare Advantage plans.

Could you post a link or two on that? Isn't happening around me. I've never encountered it or heard of anyone else encountering it.

 

[T.G.G. Moogly]

In my area, more and more health care systems are declining patients with Medicare Advantage plans.

Could you post a link or two on that? Isn't happening around me. I've never encountered it or heard of anyone else encountering it.

Okay, I did a bit of googling. It seems 1% of non-pediatricians do not participate in Medicare.

 

[gmbteach]

I do believe that you would favor caring for society’s needy, @Bomb#20.
I just don’t know how you envision such care being administered, because you seem to find fault with every institution or mechanism that purports to try to do that.

Perhaps clarifying your vision of how caring for society’s needy could/should happen, would silence some of your critics.

My vision doesn't really involve me telling others how to do it -- I'm an electrical engineer, not a health care economist. In my ideal fantasy, American politicians would admit to the public that they aren't health care economists either and aren't competent to design a better health care system, so they're outsourcing it to somebody who's good at it. They'd collect quality-of-results statistics from all the single-payer and mixed public/private systems in other countries, identify who has the top-rated system, and hire that country's experts to rebuild the American system in its image. Based on the WHO's numbers, that means we'd bring in the French.

(But that said, I know my country, so I'm confident that if we actually tried to hire French experts to tell us how to duplicate French health care in America we'd find some way to screw it up. And in any event, the chances of us following their instructions correctly, while low, are quite a bit higher than the chances of our politicians admitting they aren't competent to design a better health care system.)

I think we don't need to simply pick which is best and go with it. Instead, how about setting up some competing systems and see what happens?

Make a UHC system. Maybe even more than one. And at the same time adapt the ACA a bit. UHC becomes an ACA option, if you take private coverage you get a subsidy equal to the age-adjusted amount the government spends running the UHC system. Yes, that means the insurance companies won't know exactly what they'll be paid until the end of the year but they're in the business of dealing with risk, I don't see this as a serious problem.

We have two ( at least) public options already: Medicare and Medicaid. There is an enormous issue with both of these: The pay for services is inadequate which has resulted in providers limiting the number of Medicaid patients they serve because reimbursements fall short of cost of service. Medicare is approaching the same issue with the providers limiting the number of Medicare patients they accept. In my area, more and more health care systems are declining patients with Medicare Advantage plans.

My concern with UHC is that politicians campaign on saving money/tax dollars and patients and providers suffer. I know it works in other countries. I do not know why we are so fucked up that it is a huge issue here.

Could the drs not accepting Medicare and Medicaid patients also come down to profits? My GP receives ~$30 per consult from the government (I think I don’t get the bill) and he pays himself and his staff and rent etc. He doesn’t shove you through the door just to get another patient in. He takes the time needed (yes he frequently runs late - so much it’s a running gag).

 

[Elixir]

Most of the General Practitioners/primary physicians around here are salaried employees of the Company that owns the Hospital. The specialists are mostly contractors who are here a day or few per month. Not good.

 

[gmbteach]

Most of the General Practitioners/primary physicians around here are salaried employees of the Company that owns the Hospital. The specialists are mostly contractors who are here a day or few per month. Not good.

The last time I saw a specialist who visited 'a day a two a month' was when I saw a podiatrist at Mount Isa Base Hospital - one of the base hospitals of the RFDS. While Mount Isa had a resident OBGYN, a couple of surgeons etc, specialty drs such as podiatrists etc, visited periodically - or you went to Townsville or Brisbane. But even then, the government flew you, accommodated you and flew you back.

I had to see an ENT because I was getting extremely bad nose bleeds all the time, and so they flew me to Townsville (one didn't visit Mount Isa), I saw him for 15 minutes - he fixed the blood vessels across my deviated septum by cauterising them, I stayed at a friends overnight and I flew home the next day. All paid for by UHC.

 

[Toni]

I do believe that you would favor caring for society’s needy, @Bomb#20.
I just don’t know how you envision such care being administered, because you seem to find fault with every institution or mechanism that purports to try to do that.

Perhaps clarifying your vision of how caring for society’s needy could/should happen, would silence some of your critics.

My vision doesn't really involve me telling others how to do it -- I'm an electrical engineer, not a health care economist. In my ideal fantasy, American politicians would admit to the public that they aren't health care economists either and aren't competent to design a better health care system, so they're outsourcing it to somebody who's good at it. They'd collect quality-of-results statistics from all the single-payer and mixed public/private systems in other countries, identify who has the top-rated system, and hire that country's experts to rebuild the American system in its image. Based on the WHO's numbers, that means we'd bring in the French.

(But that said, I know my country, so I'm confident that if we actually tried to hire French experts to tell us how to duplicate French health care in America we'd find some way to screw it up. And in any event, the chances of us following their instructions correctly, while low, are quite a bit higher than the chances of our politicians admitting they aren't competent to design a better health care system.)

I think we don't need to simply pick which is best and go with it. Instead, how about setting up some competing systems and see what happens?

Make a UHC system. Maybe even more than one. And at the same time adapt the ACA a bit. UHC becomes an ACA option, if you take private coverage you get a subsidy equal to the age-adjusted amount the government spends running the UHC system. Yes, that means the insurance companies won't know exactly what they'll be paid until the end of the year but they're in the business of dealing with risk, I don't see this as a serious problem.

We have two ( at least) public options already: Medicare and Medicaid. There is an enormous issue with both of these: The pay for services is inadequate which has resulted in providers limiting the number of Medicaid patients they serve because reimbursements fall short of cost of service. Medicare is approaching the same issue with the providers limiting the number of Medicare patients they accept. In my area, more and more health care systems are declining patients with Medicare Advantage plans.

My concern with UHC is that politicians campaign on saving money/tax dollars and patients and providers suffer. I know it works in other countries. I do not know why we are so fucked up that it is a huge issue here.

Could the drs not accepting Medicare and Medicaid patients also come down to profits? My GP receives ~$30 per consult from the government (I think I don’t get the bill) and he pays himself and his staff and rent etc. He doesn’t shove you through the door just to get another patient in. He takes the time needed (yes he frequently runs late - so much it’s a running gag).

My health care provider is a large non-profit. I used to work for them (tiny cog within a cog within a cog sort of thing). Perhaps 25+ years ago, I briefly (1 year) worked in the business office of the local medical clinic and learned from those whose job was to get paid by insurers that Medicaid reimbursements fell short of the actual cost of providing treatment and Medicare was getting close. When I worked at my (real) job at the much, much better medical system, I worked in a lab and was pretty far removed from billing. Still I knew a fair amount about what things cost for blood tests analyzed in my area, from labor to cost of equipment, reagents, testing kits and supplies, etc. In fact, for a while I was assigned a project to determine actual costs to perform a specific test (you do not want to know). So at least part of the problem for some providers is that the reimbursements from Medicaid simply do NOT cover the cost of performing the necessary testing and exams, etc. The provider takes a loss on those patients, just as it takes a loss on those patients who never do pay their bills for whatever reason.

I still get my healthcare from the same very excellent health care system where I worked for many years (my real job) as does my husband. The doctors are not paid per service nor are they paid on an hourly basis: they are salaried. When you see a doctor there, you are not rushed in any way. Indeed, you feel very much as though you are the ONLY thing the doctors need to attend to for the entire day. Obviously, the doctors see multiple patients throughout the day, and there are nurses and PA who take vitals, screen you for areas of concern, etc. before being seen by the doctor. In that same system as a lab tech, I was paid/hr. as I am certain the nurses and most of the other personnel are paid. It is an excellent system if you are a patient and I have zero complaints about my compensation as an employee.

I will say that the dynamic of that system has changed and they operate more like a regular business than they used to, with more concern for bottom lines, etc. But the system of care seems not to have changed, whether you are going for a routine physical, follow up care or for major concerns/surgical needs. Care within the system is coordinated extremely well--if you are traveling from out of town with multiple appointments, they schedule those appointments so that they are as efficient as possible and if there is a need that arises during one of those visits, they get you in immediately to see who you need to see for that issue. Honestly, I'd love to see that system replicated everywhere in the US until/unless someone could demonstrate a better system.

 

[Toni]

In my area, more and more health care systems are declining patients with Medicare Advantage plans.

Could you post a link or two on that? Isn't happening around me. I've never encountered it or heard of anyone else encountering it.

Okay, I did a bit of googling. It seems 1% of non-pediatricians do not participate in Medicare.

You see a pediatrician? Medicare would not cover any such visit.

 

[Toni]

In my area, more and more health care systems are declining patients with Medicare Advantage plans.

Could you post a link or two on that? Isn't happening around me. I've never encountered it or heard of anyone else encountering it.

1 million+ patients lose coverage as insurers, hospitals drop Medicare Advantage • Stateline

HUNTSVILLE, Ala. — Libby and Andrew Potter usually ignore the avalanche of Medicare Advantage ads that land in the mailbox at their home in Huntsville, Alabama, each fall as Medicare’s open enrollment period begins. Libby, a retired middle school librarian, has what she considers good health...

stateline.org

 

[Toni]

Don't get me wrong: In theory, I am absolutely 100% in favor of UHC! I'm very much concerned about how that plays out in reality. I wonder very much how stellar medical care systems in the US such as Johns Hopkins, Cleveland Clinic and Mayo Clinic and a few others will be affected and what it means. Heck, I'm worried about how I will be affected when my husband retires and we go on Medicare. Less so for myself than for my husband who has had more than his fair share of serious medical issues that were discovered and dealt with by our very good providers/system. If we had relied on our town's medical clinic, I would be a widow, for certain, likely after years of serious declining health for my husband. This is based on how they dealt with--or failed to deal with a serious issue some years back that was effectively and efficiently dealt with by our current health care provider with a minimum of drama. No thank you. I prefer my hubby above ground...

UHC would have the large advantage of not needing the same level of bureaucracy to process payments and coordinate payments and care. That alone would be a huge savings. I am mostly concerned with politicians playing politics with 'cost savings' measures.

 

[robnisch]

Where I live it is more a lack of doctors than a Medicare issue. The only way I got to see a doc was because my sister asked him to take me on.
The local hospital has most of the clinics here and they are under staffed and are not taking new patients.

ETA: I have only had video calls with him. seems to be the way it is done now.

 

[T.G.G. Moogly]

In my area, more and more health care systems are declining patients with Medicare Advantage plans.

Could you post a link or two on that? Isn't happening around me. I've never encountered it or heard of anyone else encountering it.

1 million+ patients lose coverage as insurers, hospitals drop Medicare Advantage • Stateline

HUNTSVILLE, Ala. — Libby and Andrew Potter usually ignore the avalanche of Medicare Advantage ads that land in the mailbox at their home in Huntsville, Alabama, each fall as Medicare’s open enrollment period begins. Libby, a retired middle school librarian, has what she considers good health...

stateline.org

Thanks! The article is primarily about United and to a lesser degree Aetna. Before I retired my employer had United for one year and then switched back to it's former insurer. United was crap. I know lots of people have United but it was a shit show for us, much less choice and much more traveling involved to access their providers. When I say shit show I mean shit show so the article does not surprise me.

Aetna is my Medicare Advantage. Their problems proceed primarily from mismanagement, at least currently.

Before retiring I asked my PCP if he would continue to see me as a medicare patient and he agreed. Because I've been healthy and required very little medical intervention over my life whoever underwrites me is getting a cash cow. I wish that were more the norm.

 

[T.G.G. Moogly]

You see a pediatrician? Medicare would not cover any such visit.

No. Just quoting from the article.

How Many Physicians Have Opted Out of the Medicare Program?

• One percent of all non-pediatric physicians have formally opted-out of the Medicare program in 2023, with the share varying somewhat by specialty type, and highest for psychiatrists (7.7%).
• Psychiatrists account for the largest share (40.2%) of all non-pediatric physicians who have opted out of Medicare in 2023.
• Less than two percent of physicians have opted-out of Medicare in all but four states and the District of Columbia, where the rate is slightly higher: Alaska (3.1%), Colorado (2.3%), Wyoming (2.3%), Idaho (2.1%), and the District of Columbia (2.0%).

 

[ZiprHead]

Why would anyone assume that a YHC would not have some form of outside rsgulation?

Who? It's the government setting the standard of care. It's the government providing the care. That's a fox guarding the henhouse.

No, it's not. It's the government providing the insurance.

 

[Emily Lake]

Has any country reverted or plans to revert back to US style retail health insurance?

No other country has ever had US style health care. We invented it. Other countries lagged behind on implementing health insurance - long enough to say "hey, tying this to employment is probably not a great idea" and come up with a different experiment to try. Some work very well (Switzerland). But trying to unwind US health care from employment is a gordian knot that is pretty much insurmountable without massive upheaval and some substantial economic impacts.

 

[Emily Lake]

Isn't insurance intended to protect from very expensive misfortunes? People don't buy house insurance that pays the water bill, but doesn't reimburse for fire or flood damage "because the premiums for such coverage would be too high."

It was, initially. The first generation of health insurance was a financial vehicle that indemnified the policyholder in the event that something major occurred. The earliest forms of health insurance, if memory serves, were largely critical illness and accident coverage that would reimburse the policyholder a specific amount if they ended up in the hospital. Most of these policies were sold to people by independent sales agents, frequently by visiting the job site.

It was after the depression that things shifted. I forget the details of history here, but there were some weird government rules in place that ultimately led to employers using medical benefits as a non-wage form of compensation to compete for employees. It grew really fast after that, and ended up being pretty popular for both employers and employees.

At some point between the 40s and 70s, that insurance expanded to include professional services, and it started to mutate. The majority of what we have today isn't really "insurance" in the historical sense, it's more akin to prepaid service coverage. Less like a warranty than like a service agreement on your car.

One of the things that complicates it is that how medicine is delivered has changed too. We have a lot of screenings that occur as an effort to find things early, we have much more sophisticated (and expensive) imaging and labs, we've got genetic testing, we've got interventions that extend life for terminally ill patients, as well as sustain life for severely immature infants. There's a lot of stuff that has become routine care that didn't used to be routine at all.

 

[Emily Lake]

My wife and I both got the current flu shot and COVID vaccination shot —one in each arm— and the total was $20 per shot for a bill of $80. Not exorbitant or unreasonable, most would agree.

If you have insurance at all, and you purchased it at some point AFTER 2014, your flu and covid vaccines should not cost you anything. They are considered preventive, and are required to be covered at $0 cost sharing provided you get them from a contracted provider. If you have the receipts, contact your insurer and aks about getting reimbursed.

 

[Emily Lake]

I have been on an Advantage plan for five years. It's criminal how much money they waste trying to get my wife and myself into these additional procedures. I just got another call today to remind me about their additional "free" service. If it was actually insurance and not a money making boondoggle it wouldn't be so expensive.

That one isn't as boondoggley as you might think it is. Medicare Advantage insurers are required to meet a bunch of quality and care metrics that CMS defines - like women getting mammograms, men getting prostate exams, everyone getting immunizations. Insurance companies that get lots of those done end up scoring higher - and that increases the amount that CMS pays the insurer to run the plan. There's a requirement for how much of the premium has to be used to cover medical costs, so the amount of profit that an MA insurer can make is capped. So that increased payment from CMS to the insurer results in lower premiums on their plans.

Basically, if you and everyone else goes and gets those "free" services, it helps keep your premiums lower.

Keeps my taxes higher though... so... pick your poison

 

[Emily Lake]

Except as it stands a lot of docs limit the number of medicare patients because it doesn't pay enough.

It doesn't pay as much as they want. That's not the same as not paying enough.

 

[Emily Lake]

The drawbacks I observe are that a lot of providers limit the number of their Medicaid ( low income) patients and increasingly, Medicare patients because Medicare and Medicaid pay so poorly, often not covering the actual cost of treatment.

Medicaid is often very low, but it can be done. Most successful Medicaid plans have very tight controls on what procedures a patient is allowed to get, when they can get them, what they have to try first, etc. They almost always require an assigned primary care doctor who you have to see prior to any treatments by any other provider (except emergency), and they require referrals from that PCP for all other services. They're very tightly managed, which places very strict limits on how much excess a provider can bill for. It's not actually the cost per service that's limiting for providers, it's not being able to send everyone for every possible sort of exam. It's being required to do an xray when the initial diagnosis is a broken bone, and not being allowed to send that patient for a CT scan or an MRI instead.

It's entirely possible for a reasonable provider to make a reasonable margin on Medicare rates. Lots of providers aren't reasonable.

Note - for the most part, actual real life primary care doctors are reasonable, and the rates for Medicaid, Medicare, and Commercial visits aren't hugely different. It's facilities and other kinds of providers that are a problem imnsho.

 

[Emily Lake]

Under UHC, no provider is out of plan, because there's only one plan, and everyone's in it.

I must be missing the boat somehow. I chose my particular advantage plan because it lets me go virtually anywhere. Sure there are costs and copays but access is certainly not a problem. I'm even covered out of country as should be. Yes, I'm healthy with no family histories of chronic diseases - knock on wood - but I don't get what the complaints are about advantage plans. Maybe the shit will eventually hit the fan but with millions of people using these things they seem to be working. Would I like to see UHC so that all the phony bullshit is gone? Yes. But that's not ever going to happen in the U.S.

There's a huge amount of variation in Medicare Advantage plan coverage and contracting, depending on 1) what insurance company you're with, 2) which state you're in. If you're in Florida, most doctors and providers will participate with Medicare and are willing to contract with with a Medicare Advantage insurer. If you're with a national company like United Health Care or in many cases a Blue Cross or Blue Shield company, then you're likely to have reciprocity for doctors outside of your state.

It's a very different story if you're with a smaller insurance company in like North Dakota.