US Healthcare insurance

[Altherion]

Out of curiosity, what exactly does one get as part of the "preventative care"? For example, what does screening and counseling for obesity accomplish? I would have guessed that they're trying to reduce the obesity rates, but if so, they're failing.

[ThinkerX]

11 minutes ago, Altherion said:

Out of curiosity, what exactly does one get as part of the "preventative care"? For example, what does screening and counseling for obesity accomplish? I would have guessed that they're trying to reduce the obesity rates, but if so, they're failing.

Cynical thought:

Given the money at stake, can the US afford a healthy population from an economic POV?  Or even a significantly healthier populace?

[Kalbear]

31 minutes ago, Altherion said:

Out of curiosity, what exactly does one get as part of the "preventative care"? For example, what does screening and counseling for obesity accomplish? I would have guessed that they're trying to reduce the obesity rates, but if so, they're failing.

They're not really trying to reduce obesity rates, at least not with any particular level of directed effort other than 'eat better' or try and exercise some. Preventative care is mostly about finding long-term illnesses early and issues that might be treatable early. 

But most doctors don't even bother addressing obesity.

Quote

Given the money at stake, can the US afford a healthy population from an economic POV?  Or even a significantly healthier populace?

Yes? Absolutely. The amount of money that it costs to deal with obesity issues is not particularly good money - that money largely comes from either hospitals eating those costs or bankruptcy. Obesity as a health industry is not particularly profitable. It's also not very good for getting donations or support right now. 

Furthermore, the US already is dealing with a major shortage of nursing and healthcare staff and it's getting worse all the time. Much like software engineering the US simply isn't meeting the personnel demand for healthcare, which makes the costs rise too. 

[Raja]

6 hours ago, Iskaral Pust said:

Aemon - "lifestyle choices" has become the polite euphemism for the obesity effect on health care consumption and costs

I understand your comments regarding lifestyle choices, though I don't necessarily agree with the stance that you're taking. To be frank, the line of comments so far decrying people that might be obese and their effect on the healthcare service are more than a little nauseating, especially the following 'patients who don't correct their diet and exercise regimens as urged by their physician and thereby progressively worsen their condition' - lots of these conditions, especially chronic conditions, have a pretty big genetic component associated with them, but I'm sure you're aware of that already. 

Furthermore, how exactly are you determine if it's largely 'personally or self inflicted?', I'm not sure how any of that work in a practical sense. There are a lot of factors at play here, and reducing it the way you have isn't really helpful, in my opinion. 
 

5 hours ago, Kalbear said:

But most doctors don't even bother addressing obesity.

I agree with that to a certain extent - PCPs that I've come across generally only have fairly generic advice that doesn't really help anyone. I don't work in the US, so I'm not sure how exactly they go about their patients, but most hospitals and primary health care centres that I've worked at have in house dieticians and nutritionists that review patient's before they're discharged. It isn't the doctors that are giving them advice re: losing weight. This is the same for diabetic patients that are seen either as an outpatient, or those that are admitted. Obviously, primary prevention is the main component here, but that, imo, is a public health issue as opposed to an issue that is relevant to your visit to the PCP. Edit - That isn't to say that doctors shouldn't be involved in advising regarding good lifestyle choice, but they're certainly not the experts for it. 

[Fez]

As usual when talk of health insurance comes up, I am once again reminded of what a bubble I apparently live in. My plan has a $1500 annual deductible, but my employer provides an annual HRA with $1500 in it to cover the deductible and my employer pays 100% of my premiums. So if I don't go over my deductible I pay nothing for my health insurance. If I do go over, and empty the HRA, then I do start having to pay the copays out of pocket; but they are all in the $10 to $50 range, depending on the service. The one bad spot is hospitalization. That's a $500 daily copay; but the copay stops after five days at least. So a five day stay or thirty day stay, both are $2500.

The real crazy thing is, I've seen the premiums. Two years ago (when we didn't even have the deductible), they varied from $6K to $10K depending on employee age; and my understanding is that they went down by more than $1500 when we switched to the deductible plan. And we have fantastic coverage of everything. So when I hear talk of employers and employees paying so much more and not having better coverage, I just don't understand the economics of what's going on.

[Ariadne23]

11 hours ago, The Great Unwashed said:

Iirc, HSA's roll over from year to year, but FSA's must all be spent within the year, with certain exceptions, such as up to $500 can be rolled over to the next year.

 

7 hours ago, Iskaral Pust said:

Ariadne -- HSA's do roll over.  Contribute every cent you can to them because you'll need that tax-free accumulation to help pay your medical costs in retirement.  

Hey thanks guys. Appreciate the info.

Raja - I want to say that, FTR, for my part, I *do not* believe that obesity is a lifestyle issue. I do think, in many cases, it may be a microbiome issue and I hope we see helpful stuff on that from the human microbiome project soon. Also, in many cases, I think, it's part of the normal way people just are.

ETA - Fez - You have the nicest employer on earth. 100% of premiums?? 

[OnionAhaiReborn]

54 minutes ago, Ariadne23 said:

 

Hey thanks guys. Appreciate the info.

Raja - I want to say that, FTR, for my part, I *do not* believe that obesity is a lifestyle issue. I do think, in many cases, it may be a microbiome issue and I hope we see helpful stuff on that from the human microbiome project soon.

I find it very difficult to accept that obesity is not a lifestyle issue when we've observed a marked increase in the rate of obesity in recent history (at the same time as people have moved into more sedentary work and cheap junk food has proliferated), and when we see sharp differences between countries, between US states, and between various demographics. 

That is not to say that I think obesity should be punished by our healthcare system, or that people who are obese ought to be scolded, blamed, or moralized at. But it's also not helpful to ignore that changing one's lifestyle- eating less and being more active- is the best treatment available. 

[Ariadne23]

15 minutes ago, OnionAhaiReborn said:

I find it very difficult to accept that obesity is not a lifestyle issue when we've observed a marked increase in the rate of obesity in recent history (at the same time as people have moved into more sedentary work and cheap junk food has proliferated), and when we see sharp differences between countries, between US states, and between various demographics. 

It's a subject for another thread probably, but take a look at rates of antibiotic use (and choices to eliminate bacterial fermentation from food production) over time and between regions.

[Kalbear]

As well as obesity being linked to poverty, to availability of fresh food, to stress levels, commuting times, education levels, rural vs urban, etc. 

It's a complicated story that is not easily boxed into lifestyle choices, especially when said lifestyle choices often don't carry much in the way of an actual choice for many people. I am often reminded of the story where poor people were given a lot more money to buy food - and the thing they spent their money on first and foremost was fresh fruit and veggies. As most nutritionists and folks dedicated to paleo or special healthy diets will tell you, eating well is expensive. 

[Fez]

5 hours ago, Ariadne23 said:

ETA - Fez - You have the nicest employer on earth. 100% of premiums?? 

Yes and yes. 

But it really shouldn't be rare; this used to be the way most employer-sponsored health insurance worked. When the switch first started, existing employees were generally made whole; getting raises to cover the new costs. But that doesn't happen anymore and employees end up with less money in their pockets. 

These days its basically only state employees in some states (and generally only older employees too, with newer employees not getting nearly as good a deal) and people like me lucky enough to work for private companies with bosses that still hold the view that employees aren't disposable and the happier they are the better they work.

[Swordfish]

1 hour ago, Kalbear said:

As well as obesity being linked to poverty, to availability of fresh food, to stress levels, commuting times, education levels, rural vs urban, etc. 

It's a complicated story that is not easily boxed into lifestyle choices, especially when said lifestyle choices often don't carry much in the way of an actual choice for many people. I am often reminded of the story where poor people were given a lot more money to buy food - and the thing they spent their money on first and foremost was fresh fruit and veggies. As most nutritionists and folks dedicated to paleo or special healthy diets will tell you, eating well is expensive. 

On the other hand there are also phenomenon like having people track what they eat leading to visibility into the fact that obese people often under report their intake.  

There are obviously a lot of factors at play, but it's s disservice to downplay the fact that personal decisions regarding diet are generally a major contributing factor.

 

 

[IheartIheartTesla]

All this talk of obesity etc..is a red herring. Once you think of healthcare as a basic right, the arguments for 'choices' should fall away.

In fact, I dare you to find me one system that many if not most Americans pay into, where one subset of people is not subsidizing another subset of people. It is almost impossible for someone to NOT subsidize someone else's, lets euphemistically call it, sub-optimal 'behaviors'. For instance, my taxes pay for public schools to be free, where unfortunately many of the students (maybe even 50%) will be below average. Am I supposed to complain about this?

Yes, I understand the counterargument that in health care, the cost of premiums are tied in to other people's health outcomes, but the cost difference isnt that high for me to make a fuss about it.

[Ser Scot A Ellison]

On 10/15/2016 at 5:31 PM, felice said:

The solution is to drop the ridiculous insurance-based model entirely; nationalise all the hospitals and pharmaceutical companies, and provide all reasonable health care to whoever needs it free of charge. Fund it via higher taxes; the total cost will be a great deal less, since it eliminates profit margins, plus all the insurance and billing bureaucracy.

Will that not reduce the number of people who want to go into medicine, as the higher salaries that go with the jobs will disappear?

[Kalbear]

Just now, Ser Scot A Ellison said:

Will that not reduce the number of people who want to go into medicine, as the higher salaries that go with the jobs will disappear?

For some, kinda. A lot of that can be solved by also solving the absurd student loan debt associated with becoming a doctor. For the most part, people don't become a doctor for the money - if you're that smart and want money going into business is far more lucrative.

Most people that go into medicine do so because they genuinely want to practice medicine, especially those who actually stick through all the difficult times.

Furthermore, the salary cost is much less overall compared to facilities/administration/malpractice insurance/drug costs as far as the cost of medicine. The notion that salaries would be particularly horribly hit is itself a fallacy. 

[Ser Scot A Ellison]

8 minutes ago, Kalbear said:

For some, kinda. A lot of that can be solved by also solving the absurd student loan debt associated with becoming a doctor. For the most part, people don't become a doctor for the money - if you're that smart and want money going into business is far more lucrative.

Most people that go into medicine do so because they genuinely want to practice medicine, especially those who actually stick through all the difficult times.

Furthermore, the salary cost is much less overall compared to facilities/administration/malpractice insurance/drug costs as far as the cost of medicine. The notion that salaries would be particularly horribly hit is itself a fallacy. 

That's a fair point.  I'm not saying medicial schools will empty out but surely there will be some loss if salaries are capped and controled.

The insane cost of higher education is a thread unto itself.

[Aemon Stark]

14 hours ago, Iskaral Pust said:

Aemon - "lifestyle choices" has become the polite euphemism for the obesity effect on health care consumption and costs, especially Type 2 diabetes and consequent problems like strokes, amputations, etc that require lifetime care and medication and, unfortunately, are often coincident with patients who don't correct their diet and exercise regimens as urged by their physician and thereby progressively worsen their condition.  You're a doctor, I'm sure this isn't a shock.  For working age people, obesity is one of the largest factors increasing the utilization and cost of health care.  If it is largely/partially self-inflicted (depending on circumstances of the individual and judgment of outsiders), should that cost be borne by others?  Same applies to smokers with lung cancer. 

For the elderly, the bulk of the cost is still tied up in prolonging the last few months of life -- generally in great discomfort -- for people who are clearly dying.  But that's a whole other topic this country is unwilling to tackle yet. 

Yet you are still making this into some sort of "moral" issue about lifestyle "choices". It's certainly true that stuff like portion sizes (been out to eat lately at "cheaper" places?) and car-oriented development does no one any favours, but these are public health problems you're talking about that are largely a function of income and education status. This is becoming dangerously close to blaming poor people for being poor. 

As for smokers with lung cancer, if quitting was a trivial thing perhaps you'd have a point. And I'd say things like premature mortality and the effects of systemic chemotherapy are more than enough personal "cost" to bear. 

I can't really speak to practice throughout the US, but I can't say it's in my experience that our ICUs are filled with elderly people on ventilators. It's fair to say that I devote a lot of my time to prevent that from happening (and I'm hardly alone in that). 

[Ser Scot A Ellison]

A tangent.  If single payer were adopted and people no longer had to bear the direct cost of health care due accidents and injuries could such costs still be demanded as part of Plainiff's suits in Tort actions.  As the cost of care drops wouldn't that hurt Plaintiff's attorneys?  

What I'm driving at is that my profession may have a monetary interest in keeping health care costs high.

[Kalbear]

1 minute ago, Ser Scot A Ellison said:

A tangent.  If single payer were adopted and people no longer had to bear the direct cost of health care due accidents and injuries could such costs still be demanded as part of Plainiff's suits in Tort actions.  As the cost of care drops wouldn't that hurt Plaintiff's attorneys?  

What I'm driving at is that my profession may have a monetary interest in keeping health care costs high.

I don't see why they couldn't be part of suits. They certainly are in many other countries, and subrogation systems are a pretty big deal about most insurance companies everywhere. 

In most suits the people aren't the ones being represented anyway - it's the insurance companies trying to get their money back. 

[Ser Scot A Ellison]

7 minutes ago, Kalbear said:

I don't see why they couldn't be part of suits. They certainly are in many other countries, and subrogation systems are a pretty big deal about most insurance companies everywhere. 

In most suits the people aren't the ones being represented anyway - it's the insurance companies trying to get their money back. 

Interesting, in single payer the subregor would be the State.  If the cost of health care is shifted to everyone via taxation would the State suing as a subregor be proper?

[Kalbear]

Just now, Ser Scot A Ellison said:

Interesting, in single payer the subregor would be the State.  If the cost of health care is shifted to everyone via taxation would the State suing as a subregor be proper?

Sure, just like it's proper for the IRS to go after tax fraud and medicare to go after medical fraud. I don't see why there would be any issue at all, though they'd probably be going after actual damages and not medical costs precisely.