American healthcare

[dneal]

It's really difficult to find an objective and comprehensive history of healthcare in the U.S., without it becoming a multi-chapter dissertation. Here's one from the NIH (https://www.nlm.nih.gov/hmd/pdf/200years.pdf), and Here's another from the Kaiser foundation (https://kff.org/wp-content/uploads/2011/03/5-02-13-history-of-health-reform.pdf).

For the purpose of this thread, this summary (https://www.griffinbenefits.com/blog/history-of-healthcare) is perhaps a happy medium.

From the last link:


As the U.S. entered World War II after the attack on Pearl Harbor, attention fell from the publicly-provided health insurance debate. Essentially all government focus was placed on the war effort, including the Stabilization Act of 1942, which was written to fight inflation by limiting wage increases.

Since U.S. businesses were prohibited from offering higher salaries, they began looking for other ways to recruit new employees as well as incentivizing existing ones to stay. Their solution was the foundation of employer-sponsored health insurance as we know it today.

Employees enjoyed this benefit, as they didn’t have to pay taxes on their new form of compensation, and they were able to secure healthcare for themselves and their families.

America’s entry into World War II also brought tens of thousands of workers pouring into the Henry Kaiser Shipyards in California, Washington, and Oregon, to meet the county's demand for warships.

Facing the same issue he did with his dam project, of providing healthcare to more than 30,000 employees working in fairly remote areas, Kaiser once again contracted with Dr. Garfield (who President Roosevelt has to release from his military obligation) to organize and run a pre-paid group practice for these shipyard workers. This pre-paid arrangement of care would eventually become the Kaiser Permanente Health Plan, which would eventually evolve into our present-day managed care system of HMOs and PPOs.

That portion of American health care history is usually cited as a pivotal moment, and (as noted in the last paragraph) became the "standard" system we have used since.

Critics rightly point out that the problem with that system is that it "hides" the true costs of healthcare. Employees paid nothing, or a pittance, for their healthcare as compared to the costs. Very few people have any idea of what healthcare costs, until they get an astronomical bill from a hospital. The system worked, until it didn't. Democrats largely tried to implement healthcare reform, and Obama was successful at getting it done although at great cost in political capital.

The Obama solution has solved very little, and republicans aren't interested in much but throwing it out with no real replacement. It's a wicked problem, and shouting hyperbole and buzz-phrases at each other certainly won't solve it; so let's try not to do that in this thread, please.

I think there is merit to the "pivot" issue - that healthcare is one of the few (if not only) expenses the average American is completely ignorant of (myself included). You have no doubt what the cost of your groceries, utilities, mortgage, car payment, etc... is, but you go to a doctor and wait to see what you will end up owing - and are often shocked (and sometimes bankrupted) at/by the bill. 30 years ago my father was charged $1500/day for a hospital room. Just the bed space. A Tylenol was billed at $7.50 per pill. That's outrageous.

One solution is nationalized healthcare, which has many problems which we can address. One is a return to the system we had before Obamacare, which also has problems we can address (namely that it is too expensive when not covered by an employer). A more recent trend is variations of a healthcare co-op. I can provide more information on that for those that need it.

I'm not really sure how to present the question here. What is the "best" solution, and what are the pros/cons? What responsibilities does the individual have, and how do we get the citizen on board? There are reasonable options, and reasonable objections. Can we discuss those reasonably?

[Empty_of_Clouds]

This LINK (https://pphr.princeton.edu/2017/12/02/unhealthy-health-care-a-cursory-overview-of-major-health-care-systems/) should provide a quick overview of the common healthcare models. Useful as a starting point I think.

[dneal]

This LINK (https://pphr.princeton.edu/2017/12/02/unhealthy-health-care-a-cursory-overview-of-major-health-care-systems/) should provide a quick overview of the common healthcare models. Useful as a starting point I think.

It is indeed. Thank you.

[Chip]

When I lived in New Zealand, I was impressed by the healthcare and accident insurance system.

[dneal]

Also, for our international friends, an addition.

It seems to me that the U.S. is a (if not the) global leader in pharmaceutical and treatment innovations, and that the profits are gained in the U.S. market. If that assumption is true (and please correct me if I'm wrong), do other beneficiaries (i.e. other first world nations) bear a responsibility for sharing those costs?

The hypothetical drug Xanaduium is sold for $50 a pill in the U.S., but available in Canada for $15 for whatever reason (laws, international agreements, blah blah). I mention this because it is not uncommon to try to get this hypothetical drug through the Canadian market and import or smuggle it back into the U.S.

[Empty_of_Clouds]

Not sure about that. If pharmaceuticals are researched and created by big pharma then I suspect it's just a market issue rather than being beholden to the US as a national entity. But I could be wrong. Not all drugs are available everywhere, and here in NZ we have an overarching agency called Pharmac (Pharmaceutical Management Agency) which negotiates (I believe) on new drugs and also stipulates which drugs get govt. subsidies applied to the consumer cost.

[Chip]

In the US, the drug industry pours so much money into lobbying and bribes (aka campaign contributions) that Medicare is not allowed to negotiate costs and private insurers are discouraged from doing so. While Republicans are the biggest recipients of bribes (aka donations), there are quite a few Democrats with their snouts in the trough.

[dneal]

Chip hits on one of the key problems (and not just in healthcare) - lobbyists. There's a reason the richest counties in America are just outside of D.C. Loudon and Fairfax counties in Virginia (#1 and 3) are wealthier than the tech regions of California (Marin and San Francisco counties, #13 and 14). Apple, Alphabet, Microsoft, Amazon and Facebook, the top 5 richest companies in the world; don't have the regional economic impact that the U.S. Federal Government does.

The problem isn't just the political graft, but the crafting of bills. Congressmen and Senators don't write bills. Their staffs usually don't write bills. Teams of lawyers from various industries do. This was a large problem with Obamacare - it was written by the people with the largest incentive (not counting citizens/taxpayers). Pharma, insurance companies, etc...

To EoC's point on Big Pharma and markets... exactly. There is a lot of money spent (and lost) developing drugs. Those costs have to not only be recouped but there also needs to be a profit if they're to survive. Most people who visit the U.S. are surprised at the number of drug commercials we have on TV. You rarely see that abroad, and it was always a shock and source of humor for the wife and I after a tour in Germany when we were insulated from that for 3 years. Want a miracle cure for minor annoyance X? We've got a wonder drug for that. Ask your doctor about it. Side effects include: explosive diarrhea, projectile vomiting, bleeding from the eyeballs, seizures, and occasional death. 10 years later, there's a class-action lawsuit and lawyers are inundating the airwaves with the "did you or a loved one experience something from said former wonder drug? You may be entitled to compensation..." It's insane.

And to come full circle to Chip's point, the regulatory agency that approves these drugs receives nearly half of its funding from the companies that produce the drugs, via "user fees".

[Chuck Naill]

I can only speak for my experience, I worked for a local supplier straight commission in the '70's and it seemed the insurance was affordable. THen later with a large pharmaceutical company where we had a good family policy. Honestly never heard people complain.

Those that got approved for Medicaide probably had access to the best healthcare because everything was covered. If you're retired military Tri-Care appears to be one of the best.

Generic pharmaceuticals are very affordable and paying cash for a 10 course of antibiotics possible using older agents.

Even later with healthcare agencies I had decent insurance experiences. The least popular with me was the ACA, but I came to appreciate because it alllowed annual checkups and the companies had to cover pre-existing(s).

[724Seney]

The best solution, from the individual's vantage point, is to get elected to Congress. Members of Congress & their families have the best and most comprehensive healthcare imaginable. And, to the best of my knowledge, it continues after they leave Office.

Of course, that is not the best solution from a population vantage point. Providing the kind of healthcare they get to all US citizens would likely result in healthcare cost comprising about 85% of our GDP.

[dneal]

So what system is advocated? What are the benefits and drawbacks?

EoC's link categorizes pretty well. There are other market ideas, like Co-ops, Direct Primary Care, Association plans, etc...

Direct care, where doctors only accept direct payment from individuals has the advantage of transparent pricing, better service, and reasonable cost. $150/month or so for a family plan that covers the majority of preventative and routine care. The problem is when you need a larger facility, and the equipment they bring. Surgeries, MRI's, etc... Some direct care physicians have discounted rates arranged for their patients, you can purchase "regular" healthcare insurance for those larger issues, etc...

It solves the administrative cost problem, and makes routine care affordable; but doesn't account for more serious problems.

[Chuck Naill]

Fly and Covid vaccines are either covered or free. Hard to complain about healthcare if it’s free and you won’t take it.

[dneal]

Chuck, we disagree on some things. We've reached an impasse on those things. Neither of us owes the other an explanation why we have come to our individual conclusions, and continued gibes benefit no one; particularly in new threads. Please don't derail this one.

[Chuck Naill]

My comments are directly related. Don’t read or put me on your ignore list if it bothers you so much.

[dneal]

Ok Chuck.

What system do you advocate? What are the benefits and drawbacks?

[Chuck Naill]

Ok Chuck.

What system do you advocate? What are the benefits and drawbacks?

Medicare for all with supplements available.

[Chip]

I'd also propose a consumer protection agency to oversee both the drug industry and healthcare in general. I've seen several articles that compare the cost of a common surgical procedure at different hospitals, with a wide variation. Part of that owes to the rise in private for-profit hospitals and part to overcharging (and simple greed) among doctors. People who are ill and need care don't usually shop around.

[Richardtractorguy]

How much should I get paid to do a carpal tunnel surgery Chip?

[Chuck Naill]

How much should I get paid to do a carpal tunnel surgery Chip?

How about $150?

[Chuck Naill]

You have to provide your own sutures.

[Chuck Naill]

I paid $120 for a washer service call. I figure both of you have the same experience time
In.

[Richardtractorguy]

Fair enough. How much do you think my overhead/year should cost?

[Chuck Naill]

I was kidding.

I’m on your side tractor guy. People ignorantly disparage medical and pharmaceutical businesses.

[Bold2013]

How much should I get paid to do a carpal tunnel surgery Chip?


Enough to pay for the OR, equipment, room staff, a decade or more of training/education, cover the insurance, cover the money loss from other medicare/Medicaid procedures, taxes and then the surgeon can get the left over scraps.

[Chuck Naill]

How much should I get paid to do a carpal tunnel surgery Chip?


Enough to pay for the OR, equipment, room staff, a decade or more of training/education, cover the insurance, cover the money loss from other medicare/Medicaid procedures, taxes and then the surgeon can get the left over scraps.

Are you an orthpedic surgeon?

[Bold2013]

No.

Wife made me promise three things before we got married, one was I couldn’t be a surgeon.

[Chuck Naill]

Good choice as it's a tough residency.

[Richardtractorguy]

Aahhh residency. Working 7 days/week with only 2 weeks off/year. I made $24K as a first year resident. LOL I liked it so much that I now teach it. 15 residents and 1 hand Fellow.

[Bold2013]

I appreciate orthopods

[Chuck Naill]

Aahhh residency. Working 7 days/week with only 2 weeks off/year. I made $24K as a first year resident. LOL I liked it so much that I now teach it. 15 residents and 1 hand Fellow.

And you might make four years and be dropped, or that's what the residents used to tell me.

[Mık Joger]

It is interesting to read what changes are taking place in the healthcare system. I recently stumbled upon an Instagram page about what is calmerry (https://www.instagram.com/calmerry_com/) and was surprised at how popular psychological therapy has become. This only says that the changes that are taking place around us lead to the development of stress, up to deep depression.

[Chip]

Over the last few months, I've read articles on how virtually every segment (insurers, private hospitals, nonprofit hospitals, doctors, et al.) of the US healthcare system has documented cases of overcharging, double-billing, charging poor patients for care that should be free, and outright fraud.

‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud.

By Reed Abelson and Margot Sanger-Katz
Oct. 8, 2022

The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.

Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.

Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost. If trends hold, by next year, more than half of Medicare recipients will be in a private plan. Soon, Half of Medicare Will be Privatized. Medicare Advantage is on track to enroll most Medicare beneficiaries by next year.

But a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

https://i.imgur.com/Vk1US6J.jpg

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html

[Chuck Naill]

Of those mentioned, Human, United Healthcare, and Ciga were so bad that our agency refused their patients for home health. The best Medicare provider was and probably still is, "Traditional Medicare. Since all hospice reverts to Traditional Medicare, those HMO providers were not a part of the equation for doing what was best for the patients and families.