Health care rationing vs. freedom to go broke

In the current debate over health care, the Right is pissing me off. They are whining about a "government takeover" that will lead to rationing and death panels, but also about runaway costs. Guess what?

You can't have it both ways.

I just got off the phone with a Major Private Insurance Company. In order to save costs, certain tests must be pre-approved. In this case, I spent about twenty minutes on the phone, first with a clerk, then with a nurse (interspersed with a number of long hold periods). In the end, the study was approved. (I've never made such a call for a Medicare patient.)

This kind of prior authorization is a bureaucratic nightmare---I could have seen two patients in the time it took to get this done. On the other hand, unnecessary tests are a big waste of money, so the private insurance company would be crazy not to throw up a speed bump.

We already ration care. The question is not whether to ration care, but how. Currently it's done by the faceless bureaucrats so feared by the right----they just happen to be private faceless bureaucrats.

The Right needs to reassess its values---do they value cost containment, absolute health care freedom, or a libertarian dystopia where the rich get whatever they want and everyone else can fuck off?

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One anti-health associate of mine used the "oh yeah like I want a faceless government drone handing my insurance claim" line. Because, somehow, a faceless private drone handling his insurance claim made him sleep well at night. I don't know. I can only handle discussions with him for a minute or 2 at a time because his lack of humanity makes me absolutely disgusted.

He falls directly in the "libertarian dystopia where the rich get whatever they want and everyone else can fuck off?" category. I'm not just me being judgemental in placing him there. His reasoning on a variety of issues is "what have poor people ever done for me?".

Another anti-health associate of mine falls into the same category, as she routinely cheers when something terrible happens to homeless people and wonders "why don't they just get a job?" Because, living her insulated life as a houswife to an executive at a computing firm who can support a family of 4 in southern california, she has no concept of 10% unemployment or how real people have to live.

I'm just 24 years old but I'm already saving as much money as I can. I'd like to build up a nice emergency fund, and one of the reasons I'm saving is in case I get cancer in the future and my private insurance company decides to just not pay for it. If that's not rationing then I don't know what is. Basically, I have plenty of reason to doubt that my insurance company will do what it's supposed to do, making it functionally useless. Any public option can't be worse than that. I just hope I don't get cancer or some other major disease before I can save up enough to pay for it.

Let's stop calling it "healthcare reform." Let's say, "insurance reform." Keeps the focus on the broken thing that needs fixing.

Magellan sent The Powers at a residential program I visit an ultimatum: prior to admission tell parents that kids will only stay "a short time" (not defined) then will be discharged home, so they better get used to the idea. If that doesn't happen, no more referrals.

I went: wait, wut?

Imagine an insurer telling a hospital that they're not happy about all the CCU admits. From now on, folks coming to the ER with chest pain must be told that they won't stay long and they'll be going home from the ER ASAP.

The Powers are not medical. They believe in "customer service," so they thanked Magellan for their helpful feedback and cheerfully promised to start doing as requested.

I am tempted to send an email to the higher ups like this:

Dear Powers,

Please have a look at those letters after your name on your stationary. Do you see "MD"? "DO"?

Are you aware that states typically do not allow anyone other than a licensed physician to render opinions on those "medical necessity" forms for long-term care facilities?

Do you realize that I cannot make a decision regarding appropriate patient disposition if I haven't laid eyes on said patient?

Do you realize that this demand is based upon an assumption about my professional integrity that is not flattering? And that if I am capable of complying, that's tantamount to a confession of guilt?

Have you ever played poker? Know what "bluffing" means?

Are you aware of the history of Magellan, which is not exactly an insurance company? They get a cut from what they extort. They has a sad today, as the turnips they've been squeezing seem to be running dry of blood.

"We already ration care."

That's another piece that the opponents of healthcare reform can't or won't see. Just as they, especially Rep. Joe Wilson, don't see that we already pay for health-care for illegal immigrants.

ISTM that the major point is that we do ration care, but that the fact of rationing does not mean that people must be sentenced to death. In fact, it could have to opposite effect.

I saw Tim Geithner yesterday at a slightly different type of "town hall meeting": he detailed the huge impact of health care on the economy.Reform is not only a moral necessity, but an economic one as well.(BTW- we're improving ever-so-slightly on that front)

By Denice Walter (not verified) on 11 Sep 2009 #permalink

I should start by saying that I am in definitely in favor of the current bills on health care reform. As a military brat and later wife of a career military guy, I can say I experienced decades of pretty good government health care, which actually improved as time went on. Everyone should have what we did. Everyone.

That said, speaking to the anecdote that opened your post, I must tell you that back in the late eighties, while being treated for an asthma attack, I was an unwilling eavesdropper in a army hospital ER; the ER doc in that ward was spending a frustrating and finally quite loud half-hour on the phone. He was trying to convince the VA hospital, which had the only mental health unit in that town, to admit a Vietnam vet who had come in manic and suicidal. The doctor was finally successful, but it tied up a lot of his shift.

What's the point? I guess that there will always be bureaucracies, delays and red tape, no matter how health care is funded. I'm afraid good doctors will always have to spend some time on the phone, advocating for their patients, just like PalMD does now. On the other hand, that veteran was in a system where someone was going to take care of him. Which is more that 46.3 million Americans can say. And that, above all, is what needs to change.

From arguments I've had, it seems to be that under insurance companies, rationing is done by how much you're paying, so the rich (and therefore virtuous) get better care than the poor, whereas under a government program, it might be done by something as nasty and socialist as... need.

Rationing and death panels are a joke - those topics aren't raised for debate, but instead are simply red herrings designed to distract from the fact that the right (and yes, a few on the left) are more concerned about a political "win" than actual reform.

@PalMD: After your time invested in getting pre-approval, what do you estimate as the chances that the insurer will actually pay with no delay? My personal experience with pre-approval has been quite uninspiring.

"I'm just 24 years old but I'm already saving as much money as I can. I'd like to build up a nice emergency fund, and one of the reasons I'm saving is in case I get cancer in the future and my private insurance company decides to just not pay for it."

The sad thing is some people actually advocate this a "personal responsibility" alternative to insurance. Of course, considering the average family struggles to save up a 5% downpayment on a house, the idea that one can save enough to pay the staggering costs of a major illness is simply not feasible.

On the upside, if Obama keeps his hand on his nuts^H^H^H^H the political tiller and pushes a public option through, you may be able to put that money towards a house, or kids, or any of the things that people should be saving for.

My oncologist and Johns Hopkins had to fight with my insurance company because he determined I was too anemic for surgery and waited two days (he operated on a federal holiday, he wasn't just wasting time). They said they weren't going to pay for those two days because they - in their insurance-company-wisdom - knew that I could have had the surgery the same day I was admitted.

JH won that fight (and he told me I wouldn't be billed - I don't even want to think about how much two days in JH's cancer ward, private room no less, would have cost), but I'm sure they spent a lot of time.

He then sent me home with a prescription for a new drug he was very fond of since you only had to take one pill a day to fight the chemo-induced nausea. My insurance company wouldn't pay for it, because it was new; he had to change his prescription to a slightly-older, two-a-day medication (which, I'll be fair, worked wonderfully well)... but I had to sit around the pharmacy for three hours while he and they and the insurance company went around about that...

My only consolation over the whole deal was that the insurance reps kept telling me that they "could see no reason" for me not to go back home and spend the six months of chemo at my parents', where my family was. And then, after I'd flown home and my sister had found an oncologist, and I'd started the blood work - then, the insurance bosses said, no, I couldn't, since the treatment was available in Maryland. I had to pay for the first round of blood work on my own. But I kept thinking to myself: no way is Baptist in Knoxville going to be as expensive for them as Johns Hopkins...

But the whole experience was crazy and involved reams of paperwork. I can't imagine how frustrating it would be to do that over and over for multiple patients.

Posted by: The Ridger | September 12, 2009 8:51 AM

My mom is a retired RN who used to do that job (and what PalMD detailed above) for a large hospital. The only people she had to argue with to cover admissions a long time ago were the medicare and medicaid drones. The HMOs started acting like Medicare/Medicaid around the early 90s, in her experience.

Over the years Tri-Care has swung from the extreme of being as bad as Medicaid to being better than private insurance in terms of getting things approved/paid for for my family. It's all very frustrating.

I would support having the government offer low-cost policy, either catastrophic or all-inclusive ... but the government would have to be very blunt up front that this low-cost policy is the Yugo of health care plans. People would need to know up front that they would be directed to county or other public hospitals and to generic medications, etc. That really is all we can afford for 300 million citizens. People expect gold-plated care for very little money now, and lots of folks refuse to pay for the insurance that is available to them, and then become outraged that doctors charge $75 for office visits and labs charge for tests. My parents drummed it into my head from the time I was looking for my first job that I must have health insurance. I worked at 7-11 in college (lousy job, people treat 7-11 clerks like trash) because they offered decent it makes me kinda nutty to talk to folks who simply refuse to enroll in health insurance plans because they don't want to spend $400 bucks a month or whatever.

It's a complicated issue, and most people are so ignorant of medical issues that I'm not terribly optimistic that politicians will get it right. I'd really like for them to try small things (like offering medicaid to more people with a serious explanation that they are getting minimal coverage but it's better than nothing and they won't go bankrupt if they get cancer or something) rather than enacting some huge change.

By military wife (not verified) on 12 Sep 2009 #permalink

Treatment justification to 3rd parties drives up healthcare costs for providers and there's not much talk about how to cap that cost.

Magellan insists on monthly hour-long treatment reviews. These meetings involved an MD, RN, PhD, social worker, and behaviorist. OT, PT, and speech provide summaries but don't attend. Add those payroll costs up --it's a lot.

Who foots the bill for these meetings? The provider, largely. On the managed care company's end there's just the one reviewer who may hold only a bachelor's degree.

I'm told Magellan now wants these meetings every two weeks, or else. I truly can't see how this will benefit patients. In a residential program, there's no intervention that changes a child's developmental course so rapidly.

For a time this facility will try to comply with Magellan's expanding demands for meaningless data. It will find itself chronically failing to keep up and promising to do more. That's the point, I think. Puts the place in a weak negotiating position.

Magellan is of course seeking the absolute bare bone bottom line, as it should. Thats why Medicaid has hired them. Unfortunately, it will go to far. The facility will foolishly think it can ride out the lean period via other funding streams. But those will follow Magellan's lead and within a couple of years the place will go bankrupt. Seen it many times.

The for-profit free-market model isn't playing out well in this arena. Non-profits have a different set of problems but their transparent finances make them less vulnerable to the hard bargain.

Call me a pinko, but I'd rather my health be in the hands of anyone rather than someone making a profit out of it: take a look at the figures here:

and see if there's much to worry about in givernment health care.

i know plenty of people who are for the libertarian dystopia option. sad to say, we have largely become a nation of selfish bastards who look out only for ourselves.

i get the outrage over people who abuse the system. but why aren't we outraged that people (MANY people) can be entirely responsible and hardworking, saving money every month and paying for health insurance, until they get sick or hurt and the insurance company refuses to pay. why aren't we outraged that these people, who by all accounts have been doing everything right and are asking nothing of anyone else, then proceed to lose their home, their belongings, their life savings, and still go into 6-figures of debt- all to pad a profit margin and add 6 cents to the shareholders' bottom line?

the insurance companies ration care as it is.

the people who are concerned about rationing of health care are the ones who presume they will have it if they need it, because they're paying for insurance. little do they know what a foolish presumption that is.

In my crazy land of Canada, neither my doctor nor I has had to debate with ANY government agency on whether or not the care set out for me would be approved or covered.

I get what I surmise after a weekend of talking to americans who don't have insurance, that included in our fairly modest taxes, ( and we're no where near povertyline), a system they envied.

I don't think most people want "gold plated", they just want the basics that are clearly ever more out of reach, and something for the unexpected catastrophic illnesses, and reasonable preventative and maintenance care.

I met more people this weekend who'd been dumped by insurers, ( including a doctor turfed off the HMO approved list for not kowtowing to the HMO beauracy, to which he said "I just want to take care of my patients!") or people who've lost insurance when they lost jobs.

I have the luxury of experiencing neither, at half what the US gov. pays out.

IE: is it cheaper to have a diabetes management clinic and affordable insulin and testing, or...hospitalizations and amputations? I suspect that the question isn't just one of reform but can the US afford NOT to have universal care of some kind anymore?

I have a very well managed chronic condition, where in the US I'd be rendered utterly untouchable by all insurances. I am ever grateful that I get a fairly high standard of care, because I, and my gov. realize an ER visit or hospitalization are far more costly than a simple visit to a doctor's office when I need to deal with an issue. ( asthma) .

Nico: awesome reply.

Funny, you didn't mention having to wait for days to see a doctor, or the rushed way he treats you blah blah blah blah.

We need more people like nico to speak up for their country's health care and hammer that into the public's eye in america.

By genewitch (not verified) on 13 Sep 2009 #permalink

I've only waited days if my doc happened to be on vacation ( much earned), I was always offered same or next day in 90% of the cases. It's far easier and preferable for her to have me dash to the office if my asthma acts up, rather than have me flop into the ER.

She stayed after hours once when I was in the midst of a miscarriage and at the ultrasound clinic, and spoke to me at length on the phone as a fellow human and patient as well. After. Hours. On her own time.

Granted, I've has some less than perfect doctors ( mostly in that bedside manner dept) , but they were ALL highly skilled, and they cared about patients, not as a billable item but as a human.

I have been speaking up, but I don't think the message hammers home into the people who truly need to hear it: universal care is a wonder and a bliss and it's something not to be feared but embraced.

I do have a goodly number of friends in the US who simply can't see a doctor because the insurer won't approve a visit. One finally resorted to going to the ER instead, after 2 years of denials with his insurer.

I can think of no other economic kick upward in the pants than to free people from prohibitively expensive insurance, and insurance tied to a job.

Spent about 5 hours at the ER with my wife on Friday. We have no insurance, so the ER is the only choice sometimes. My wife could barely walk between the edema in her lower legs and feet (and hands) and the pain that went with it. The physician on duty made it very clear (in his broken English) that he did not want us in his emergency room for something like this. His diagnosis (with only his brief visual exam): arthritis. He did call for some blood work, the results of which were never shown nor explained to us. My wife got a scrip for Naprosyn and we were sent on our way. No idea how she's going to get through work on Monday, but that's how it goes when you're poor and in pain. I guess the right-wing conservatives would rather we curl up in a corner out of their sight and die.

Yes, health insurance reform is necessary, but health care reform is right up there on my list as well. Granted, if we had universal health care, we would not have had to wait so long that an emergency room visit was necessary.

dan--there are low cost or even free community clinics all over the country. your wife will get compassionate, decent care. call the closest public or county run hospital to get the locations of your choices. you may have to ask for the social services/social workers or something.

they are out there, and they are staffed by good doctors who take a day to volunteer or who retired from private practice but want to help. I know doctors who work at some of them, and have family members who have worked the dental equivalent.

don't give can find help for your wife

By military wife (not verified) on 13 Sep 2009 #permalink

My 50th birthday present from Blue Shield? A $125 jump in my premiums since I am now "old". I have never smoked, I'm slightly underweight for my height, I work out, ride bikes and walk everywhere. The only thing remotely serious to happen to me medically was a colectomy two years ago that had a very good outcome. I take no prescription drugs and my monthly insurance premium is now going to be equivalent to a lease payment on a new BMW 3 series.

The insurance company can't be blamed. The 10-year risk of having, for example, a major cardiovascular event go up steadily with age until they reach nearly 100%. The insurance company, even a non-profit, must find a way to pay for that, and since there is no incentive for millions of healthy people to join the ranks to pay for the rest of us...

This is where a single-payer plan, like Medicare for all, would immediately solve at least one problem.

I worked at 7-11 in college (lousy job, people treat 7-11 clerks like trash) because they offered decent it makes me kinda nutty to talk to folks who simply refuse to enroll in health insurance plans because they don't want to spend $400 bucks a month or whatever.

There is a certain element, especially among younger folks (ironically, the ones who, not yet having acquired a pre-existing condition, are best placed to start an insurance plan) that they don't need to spend $400 a month on something like health insurance.

But there are also plenty who don't want to spend $400 a month on health insurance because they'd rather spend that on food, rent, utilities, etc. It's a blessing if you can find an unskilled job that has health insurance, and the big chain stores are great for that. As much as we all like to rail against the encroachment of big companies on small businesses, the need for health insurance makes big corporations a lifeline for many people. An unpredictable lifeline, unfortunately, because they tend to be more cavalier about their employees. (Petco closed a store in West St Paul, giving the employees a grand total of eight hours notice that they were out of work. Not fun. Small business can be mean too, of course, but it's harder to be mean to your employees if you see them face-to-face every day.)

But somebody has to work for those small businesses. And then there are the self-employed, and those who are essentially laborers. They don't get benefits. They may get tips. But they don't get health insurance, and if they're only making $8.50 an hour part-time, $400 a month on health insurance is actually impossible to pay. Not just annoying, but impossible. (And $8.50 is above minimum wage.) Even before taxes, that's about $1,360 a month. Unless you have low rent, can walk to work and have no dependents, you may be able to afford a $400/month premium. But most people will not be so lucky.

I think that's what's really killing small businesses and the family farm -- the fact that the burden of caring for society is falling increasingly on our employers. How long before we have company towns again, or before we become indentured to our employers?

By Calli Arcale (not verified) on 14 Sep 2009 #permalink

military wife, those clinics aren't all over the country, at least not enough for many people who really need them to have access. I live in a city of around 50,000 people that's surrounded by a lot of farmland. We have one such clinic that's open once a week. It hasn't taken new patients in years. I wonder who can't make it to bigger cities hours away and I wonder how many places in those bigger cities take people who aren't locals. I wish you were right and they were all over.. but I'm afraid that greatly depends on where you live. Certainly does around here.