No, I am not suggesting at all manner of dress or behavior affects culpability for the crime. Behavior simply affects outcomes.

Of course, the law can be changed to require everyone to be covered (as part of community rating reform or seperately from it). Pre-existing exclusion prohibition is another reform I have listed numerous times. It gets ignored, because reform hasn't been the goal here, but government takeover.

The same is true about prohibiting recission (cancelling or reducing coverage after you get sick).

That's right, they are under no obligation to cover everyone. One of the issues around healthcare is that more people SHOULD be covered. And what about people who pay for health insurance all of their lives but never use it (except for an occassional check-up). When they're older they inevitably experience health problems, perhaps cancer, and then may lose coverage and need to buy it on their own (especially in this day and age where thousand of people lose jobs and health insurance everyday)?

I mean what's the incentive for healthy people to have health insurance if they lose it for whatever reason and then can't get it when they actually need it?

I might as well cancel my health insurance now, save some money and not pay for others' treatments for their “approved” illnesses.

True, but it's also easy to see how the opposite can occur in some systems and to me personally, I think some European societies have reached that end of the spectrum or are at least approaching it.

I mean there are a lot of cases where most people who aren't too emotionally blinded by closeness to a situation would agree that treatment is going too far to artificially extend a life (a 'can't define it but you know it when you see it' sort of thing), but then there are also so many cases in the gray area where you and I might easily disagree. Keep in mind that in my profession I deal with end of life/ quality of life decisions all of the time, and it's interesting to note that a financial liability toward the medical care involved certainly adds a different dimension and it's something I'm always sensitive to. In addition, of course, there's a level of difference based on animal life vs. human life and for me that's very significant because I have very different spiritual/theological views on the two.

I'm not really sure where I'm going with all of this, except I guess to say that it's all pretty complex without a neat solution.

I will write about this more explicitly at some point as I am kicking around how to phrase things.

Thanks for the link. I did read it and found the perspective interesting and informative, but as you suggest, not enjoyable.

tidbits

While it's true end of life decisions should be individual, there is a systemic bias to keep people alive as long as possible, and that greatly influences patient/family decisions. And I agree that there is no way to have an empirical formula, but a lot of cases it's just insane. I bet I could spend a week talking just to my immediate contacts and get three dozen of examples of current cases with multiple organ failure and in need of organ transplant or suffering from something that will kill them in the next few months anyway that are shuttled around from department to department ot get $100k surgery after surgery and go into more and more pain (to the point where they have to be kept unconscious basically the whole time). I do think it's an injustice that this is occurring although I have no idea how to address it. I guess addressing it at all — without screaming death panels — would be a start.

It goes back into my general problem with societal egoism, which in this case I think manifests as an unhealthy focus on being alive as opposed to living. I'm not saying this should be addressed politically, I'm talking about a deeper more individual and spiritual argument.

But note that there too, the companies are still basing their decisions on their spreadsheets and that's why I say that the expectations (and basis for policy) should generally always assume that will be the case and then anything above and beyond that is just gravy.

Systemically there are things that can be done to help promote the environment in which the consumer pressures are better aligned to the hoped-for goals (helping small firms compete, and antitrust laws to prevent or correct for businesses that are too large to have those pressures on them and too faceless to have any of the personal relationships and accountability that help.) But that's still different from naively thinking that companies will just act as good neighbors because it's the right thing to do.

The foreigners I talk to (primarily from India and Europe) are adamant that companies that try to be faceless amoral spreadsheeters lose business in the long term either because people won't frequent them as much or (perhaps more often) they make bad long term decisions for short term gain, and when they mess up there is no sympathy and they go away.

The problem though is that any of the types of reality based solutions you mention to limit coverage when it 'makes sense' will be looked at by the affected population as the same type of argument you feel is being made in a case like this one. It's really not possible to set an empirical formula about quality of life and end of life care because each individual and family affected will define those things differently. Ideally, more people would make the personal decisions ahead of time because once things happen it is too late to determine the wishes of the affected patient, and most people aren't very comfortable with bureaucrats of any sort (private insurance companies or govt entitities or doctors acting as agents of a hospital bureaucracy) deciding when enough treatment is enough.

I do think there's a very rational line though between a real insurance model which pools against future risk and the pretense of calling it insurance when the risk has already happened. We accept that with all other types of insurance (can't call up Geico and get them to issue a policy after an accident has occurred.) That's why I think it's rational to separate out the issue of preexisting conditions and figure out a different financial mechanism to assist in paying for their health care costs.

http://shakespearessister.blogspot.com/2009/10/…

ETA: Perhaps “enjoy” is the wrong word, but I think you'll find it very compelling.

They're under no obligation to cover everyone. Lay aside the future where advances in genetics will make predictability of future diseases even more prevalent, as well as the problem with the “insurance” model being applied and “insurance” being misused (the way “social insurance” is — a stupidity!) when what is conceived and sought is comprehensive health care (typically including preventive, etc., care).

“Community rating” would address tha. That term means forming everyone into a single pool, and you can even have everyone pay the same thing, which is what I mean about having equal or identical “per capita” charges for “premiums.” (This is different from “experience rating” and other risk-assessment and -distinction forms of insurance, which shouldn't be surprising to anybody given what insurance is.)

I've mentioned community rating for months, as well as other reforms that are real reforms, but neglected, because the current object of interest isn't reform, but federal takeover of health care.

* * *

“It's no different than what we now do with Medicare (which pays out for medical care of the known high risk groups of senior citizens as well as patients with end stage renal disease) and with the national flood insurance program.”

Well, Medicare applies community rating to the qualifying age group that Medicare is generally known for, but the others do form a risk pool. And the “high-risk pool” is the normal alternative (and item I have written about before — perhaps too many people simply think all the time about what they want, a magic new government solution that will be Nirvana, rather than read what people have to say, and actually realize what the facts are). Typical high-risk-pool members are AIDS and cancer patients, for example. So many of these people can't get good, cheap insurance, but they do get insurance, nevertheless; it just costs a lot (and often is limited, unless state-law minima require generous benefit packages, but then it becomes that much more expensive). Then there are other details — for example, Blue Cross (a company notorious for being very profit-making despite its “non-profit” heritage and even nomenclature), here in Michigan, is officially the insurer of last resort (and offers individual policies, anyway, so I was able to get one without a problem, and it's pretty good, at a quite reasonable $300s per month, in fact).

The short answer is yes..but with caveats. It would have to include systemic changes that people don't want to talk about (such as how much money is wasted on people with very poor quality of life in their final days) and the like.

That's what I meant about the process instead of the outcome, I was just scattered. There is no way to do it currently and the insurance companies can't do much about it as it is so systemic, but there is also the feeling that there is no attempt to try, and talk about what could change in order to make it possible.

I don't mind arguments like “well we can't cover people that are a high cost to insure because of this and this and this and this, that's where we should focus on seeing what is possible.” I just am tired of arguments that dehumanize the people involved and suggest they use complex loopholes or not leave their drink around or accept that their financial life is destroyed because they weren't lucky and anyway, tough because I got mine [obviously you're not that type].

You have far more faith than I do that people will drop the 'evil corporation' meme. And frankly, although it is a nice lagniappe for businesses to go above and beyond what regulations require, I don't buy into the idea that this should be expected. Conscience doesn't exist at the systemic level, and we shouldn't operate on the basis of that expectation. Just create the regulations needed, and enforce them. If/when some companies go above and beyond that, great. Otherwise, assume that many or most will make decisions based on spreadsheets rather than a moral compass.

And one thing that I was focused on, which I don't think you're really accounting for, is the high cost specifically of insuring someone with a preexisting condition. You mention the potential IT savings as being enough to 'cover everyone who needs coverage' but that population consists of two distinct groups- those who just lack insurance but are average actuarial risk individuals, and those who are at 100% risk of being high cost to insure. Are you really accounting for how much it will cost to extend coverage to all of those individuals?

I would also add to that that there is currently no attempt to control costs at the different levels of the supply chain, which is another issue, and that Rand has projected that if we have a mere 4% annual efficiency increase in productivity (primarily due to better IT infrastructure) then it would save $500 billion-$1 trillion annually in 10 years. That is more than enough to insure everyone that isn't currently. In fact on a prior post I pointed out a Kaiser study that says it will only cost $80 billion more than what is current spent (so in 10 year dollars plus overshoot, let's say $150 billion…still far below the savings projected by Rand).

Now you may argue that insurance companies aren't responsible for all that and can't fix it all, and I agree. But they do have an extremely major part to do, both in moving towards that direction and patient education.

I don't think that for profit companies should be forced to do charity (although I do think that critical areas like this need lots of nonprofit competition) but I also believe that they have a moral social obligation to try to be as upstanding as they can be. At the very least, that is developing a personal relationship with a patient or prospective and making decisions based on that, instead of looking at them as an actuary would. It's not just in this, banks that did the former turned out alright, even lending subprime, while those that did the latter are in awful shape.

A good amount of stories that get people upset are based on stupidity that I will call sociopathic because it shows no empathy. I love the definition of empathy that it's being emotional enough to put yourself in another person's shoes while being objective enough to analyze the situation. A lot of times their behavior isn't empathetic in that they don't care, and they are either going back on their word or they are denying something for a reason that is no good.

If they started being more empathetic and explained how they can't afford to take on high risk people due to systemic factors, explained those and tried to be leaders in changing it, then I believe that vast majority of people would understand their position. However the current feeling (which is correct) is that they are just out to screw you over and it's only when they are legally forced to do something — or someone has reams of time and knowledge to fight them on their footing — that they begrudgingly cough up.

And God forbid you don't qualify for HIPAA for whatever reason. You're basically at their mercy then.

This isn't just health care, but corporations in general I'd add.

“As for a general single payer plan- although it wouldn't be my preference at all, at least it makes more sense than most of the hybrids that have been proposed.”

Ah, we have found our point of agreement.

Because it is victim-blaming CO. Not everyone has street smarts, though I'm glad that you and your daughter do. The rapist is the criminal. He is not any more or less a criminal based on whether his victim did or did not have “street smarts”. The woman didn't ask for it because she wore a short skirt or because she didn't have the “street smarts” to order a new drink, or because she was flirtatous or because she had too much makeup or because, because, because.

Blame the criminal, not the victim. And, just a note, there is no evidence in the story that this woman ever left her drink. She may have looked away for just a few seconds or been distracted by an accomplice. I really think you need to re-examine this instead of trying to defend it. The same logic, street sense, could be used to suggest that all women wear burkas, lest they tempt a criminal to rape.

I don't actually think the Medicare system functions that poorly though- it's just too expensive (and contrary to what many of the critics of private insurance say, part of the problem is actually that the admin costs are TOO low, which means that there isn't enough internal control over fraud and abuse.) To me, that's an argument to fix the flaws with it, and then run cost analysis to see what the additional taxpayer burden would be to add the high risk pool of individuals to that system. My guess is that although we'd still be incurring more liabilities for the taxpayers, it would likely come at a lower price tag than what is currently on the table for 'reform'.

As for a general single payer plan- although it wouldn't be my preference at all, at least it makes more sense than most of the hybrids that have been proposed. This is one of many cases where political moderation isn't actually a good thing if by that we mean taking the extreme ideological positions as a starting point and then watering them down until they're politically palatable. That kind of 'negotiation' for a centrist position often produces the worst of all worlds instead of the best.

I say to you what I said to EEllis. You make a good argument for single payer where the taxpayer costs of high risk can be offset by the profitability of insuring the healthy in a single pool. Don't mistake this for supporting single payer, but there is a sense in which it makes more sense than giving the gravy to insurers while making the taxpayers eat the gristle.

The fact that this is similar to what we have now with Medicare is, I'm sorry to be disagreeable, not very convincing given how poorly the current system works.