05 March 2009

Case study in the need for health reform

Time's Karen Tumulty has a great piece up today about her family's experience with the health insurance industry.   Go read it.

Some key points:
  • Insurance companies are evil.   This is a pretty classic case of a company retroactively canceling a policy because the policy holder developed an expensive condition.   Health care reform, with guaranteed issue and community rating will go a long way towards restraining the bad behavior of the insurers.
  • Underinsurance is as serious a problem as uninsurance.   This patient did the right thing (as far as he knew) -- he paid for private insurance, high-deductible, out of his own pocket.   It turns out that he bought the wrong policy for a number of reasons.   Even if Assurant had not canceled his policy, when he hit his next renewal date, he would have been freshly underwritten with his new chronic condition, and the cost of renewing the policy would have been well beyond his means, or would have been excluded as a pre-existing condition.
  • Texas is not a state to live in if you are poor and sick.  25% of the population is uninsured and Medicaid only covers those making less than 21% of the poverty line!   Holy crap.   So much for compassionate conservatives.
  • Preventative care saves both lives and money.   This is a great case study in which a patient may wind up falling out of the work force, hurting the economy and becoming a ward of the state, because of his chronic disease.   Not knowing his diagnosis, it's impossible to say that in this case preventative care would have kept stage 1 or 2 chronic kidney disease from progressing to stage 3 or 4, but across all comers it is certain that significant numbers of patients will benefit.
  • The uninsured really get screwed with health care costs, when they have to pay the gross charges instead of the negotiated rates given to insured patients and medicare patients.  Of course, most don't pay, but it adds to their economic burden anyway and accelerates the slide towards bankruptcy.
  • Half of bankrupties are in part due to medical costs.
A timely article, well-written, and full of insights into the current reform debate.


  1. Golly, where does one begin with heart-rendering story--which proves absolutely nada?? First, we have an individual with developmental concerns managing his health and welfare without assistance. The concerned family jumps in later, after the problem has grown like Topsy. Second, he has not seen an MD for a routine screening, which probably would have caught the prodromol signs of renal disease. Bad things often show up after a long absence of preventative care. Who kept him from the free clinic?? Third, this gentleman wasn't "underinsured", he was wrongly insured...covered by a product designed for a totally different purpose. Finally, can we stop repeating ad nauseum the saw about 48 million or so "poor" uninsured folks? After you factor OUT the illegal aliens, the households with $75K who can't "afford" insurance, and the young and healthy playing the odds, the number drops to 25% of this oft-quoted number. *sigh* Pattie, RN

  2. 3/4ths of the live births at the county hospitals in Houston are to illegal aliens. We don't need universal coverage, we need better border control.

  3. I know this is long, but you done done it now, Dr. SF. You done messed with Texas...

    Texas is not a state to live in if you are poor and sick. 25% of the population is uninsured and Medicaid only covers those making less than 21% of the poverty line! Holy crap. So much for compassionate conservatives.

    In defense of Texas, that 25% uninsured figure is very misleading. Texas has one of the highest populations of illegal immigrants in the nation, and most, if not all, are uninsured. If you were only counting legal residents and citizens in your figures, I am sure the number would be more like the national average. Accounting for illegals also drives up the number of uninsured and unimmunized children in our state. There is a resurgence of some diseases in parts of Texas that many doctors elsewhere have never seen in their careers.

    Still, thanks to EMTLA, those poor criminal aliens get treated at our hospitals, and bankrupt our medical systems. (Houston/Harris County Medical District lost over a BILLION dollars in 2007 providing medical care to illegal immigrants. That's BILLION with a "B"...) Because they are considered indigent, they also qualify for certain Medicaid services despite their illegal status - so illegal immigrants are draining state and federal resources that would have otherwise gone to legal Texas residents. No wonder Texas is stingy. So given the fact that we are not carting busloads of sick illegals back to the border and dumping them over the fence, I am not quite sure how Texas gets singled out by you as demonstrating a lack of "compassionate conservatism", other than the fact that we are a proud red state and red states make you foam at the mouth.

    So, yeah, 25% is a "Holy crap!" kind of number, but it's not the whole story - which, of course, we won't get, since there is no way the liberal media will do anything to undermine The One's goal of socialized medicine. And if you think for one minute that your universal healthcare utopia is going to improve the issues related to uninsured Americans without addressing medical care for illegals, you need to step away from whatever it is you are smoking.

    The writer also makes a statement that stuck in my craw. She writes “The idea is that they (meaning average Americans) would be the ones best equipped to decide which (healthcare) plan suits their individual needs. Pat's experience suggests it is difficult for an individual to make such judgments.” Remember, her brother has Asperger’s – so yes, he may have trouble understanding the complexities of choosing an insurance policy. But he is not an average American – she is falling into the typical liberal mindset of assuming that the average American is so stupid and helpless that he or she needs the government to step in and save them from themselves. I have to choose a policy for myself every year from my employer – there are different levels of coverage, different deductibles, different premiums – no different than if I were looking for coverage on the open market. I have to assess and make the right choice for me and my family. So knocking the plan supported by Republicans by saying an individual is not able to make such judgments is rather insulting.

    She then tries to smooth over the insult by saying “The individual health-care consumer has very little power or information.” But in the very next paragraph, she says how easy it was for her brother (the one with Asperger’s, remember?) to get ON THE INTERNET and file a complaint against his insurance company. So Americans can use the internet to file a complaint, but they would not be smart enough to use the internet to obtain information about private policies or research the companies and what they offer?


    This wasn't a case study - this was a unique circumstance masquerading as a common occurrence - not to mention a liberal hatchet job on texas.

  4. Okay, Texas' unique situations aside--how do you insurance industry apologists account for the fact that the United States is the only developed nation in the world whose government does not provide its citizens with health care? Anyone want to explain why and how the disproportionately high per-capita health expenditures in the States (health care expenditures borne by the individual and his purchased insurance, I mean) translate to less successful outcomes here? Why do we have the highest obesity rate in the world? Why do we have more people go bankrupt due to health crises than anywhere else in the world (do people even go bankrupt due to health crises in other countries?)

    Perhaps you can explain why my mother-in-law, whose husband served in WWII and who has paid taxes since she was a working teenager, usually had to sit--for eight to ten hours--in the waiting room with my late father-in-law for a simple well-care checkup at the V.A. (and they considered themselves lucky, because they only got billed for medicines and auxiliary services). And why she must now fork over part of her meager Social Security check to pay for Bush's "prescription coverage" plan for the privilege of paying (still) more than her Canadian friends do for medicine she needs, and why her family, who are themselves struggling to keep everyone insured, has to fill in every month so she doesn't starve or fall short of any needed meds?

    This stuff doesn't happen abroad. Even in the more right-leaning countries, healthcare is considered a moral imperative and no-one would consider opening it up to the profit motive, wherein a company must choose between that which is right and that which satisfies fiduciary duties to one's shareholders.

    I can't believe Americans put up with this; hell, I can't believe there are some Americans who hold the attitude that this is somehow all about "freedom" and "choice" and that we'll lose those things, somehow, if we direct our government to pay for its citizens' health care instead of lining defense contractors' pockets. It's unconscionable, truly unconscionable. More so when the apologist hail from the healthcare profession itself.

  5. Half of bankrupties are in part due to medical costs.

    This stat is about as honest as the tax return of an Obama appointee. It comes from a phony "study" by a couple of PNHP zealots and it has been shot down repeatedly by legitimate studies, one of which can be found here.

  6. Less successful outcomes? Excuse me? We pay more for health care in this country because it is the BEST health care in the WORLD. Just because it is available cheaper in other parts of the world does not mean it is better - I can get a boob job on the cheap in Brazil, but I have a better chance of dying from complications there too. After the R&D is done in this country at a cost of billions of dollars, doctors in other countries can piggyback off of our expertise and reap the benefits with none of the costs. I live in Houston - if you go down to the world famous MD Anderson Cancer center on any given day, the lobby looks like the departure lounge for an international airport. My husband and I waited with our son in the lobby of Texas Children's Cardiac Care center with people from three different continents. If healthcare is so great in other places where the nanny state pays for everything, then why do people come to Houston every day for care?

    Your in-laws waited long waits at the VA because it is a GOVERNMENT managed system - hello, bureaucracy, anyone? The horrific wait times in some ER's are, in my opinion and the opinion of many medical folks, directly attributable to government interference, which not only slows down the process with overzealous regulation but also by allowing for abuse of the system by a certain segment of our society.

    Want a good example of how our medical system will turn out if The One and Dr. Shallow Facts gets their way? Look no further than our STELLAR public education system. “An education is a moral imperative!!” – so it is now government mandated, hyper-regulated, and full of unmotivated, unqualified, undercompensated teachers and administrators. Our public schools regularly get failing grades, and we as a nation are woefully behind other countries when it comes to educating our children. Why? Because government interference removed the motivation for a teacher to succeed at his or her job. The best and the brightest don’t become teachers because there is no reward for hard work. The worst become teachers because it is a job for life – it takes nothing short of a murder conviction to get a teacher fired in this country – so they can sit on their asses and do nothing and make a paycheck. The worst teacher and the best teacher are compensated exactly the same, so why bother? Because this is a taxpayer funded system, salaries are woefully inadequate – heaven forbid that tax dollars be spent to pay someone a good salary, even though they have a vitally important job – educating our children!!! And this is what you want for our medical system? If someone acquires massive debt and devotes ten or more years of his or her life to the study of medicine, why should they have to give away their skills for free? Take away the profit motive, and our doctors will wind up like those public school teachers - other than a talented few who are truly in it for altruistic reasons, they will be unmotivated and unqualified. Would you want someone doing open heart surgery on you that didn’t give a rat’s ass? I thought not.

  7. Less successful outcomes? Excuse me? We pay more for health care in this country because it is the BEST health care in the WORLD.

    You forgot to say WOLVERINES!

    Seriously, though, the numbers are all there if you want to Google them. The US certainly has good health care for those who can afford top-drawer medical coverage (and who are lucky enough to never fall ill and have their sickness declared a "pre-existing condition" that terminates their coverage). And the US undeniably spends more per healthcare dollars per capita than any other nation (the Henry Kaiser foundation has a good study on this). But with all that amazing, WORLD'S BEST healthcare, you'd think that Americans would have the longest life expectancy, right?

    No. The US is well behind Italy, Israel, New Zealand, to name just a few.

    Well, surely the US would have the lowest infant mortality rate, right?

    No to that, too.

    Perhaps, rather than view criticism of the current system as an attack on the providers and innovators, it would be more clarifying to view it as a call for better efficiency. In 2006, health care expenditures were 15 percent of GDP in the States, as compared to just 11 percent in France and Germany, 10 percent in Canada, and 8 percent in the United Kingdom and Japan. Yet Americans are not enjoying longer lives; they do not have easier access (or, for some, any access at all) to the preventive care that demonstrably improves quality of life as well as lowers healthcare costs over a lifetime by identifying and addressing problems (i.e. obesity) and progressive illnesses early on; and they cannot boast of anything close to a low infant mortality rate (a statistic that dramatically changes when free prenatal and neonatal care is made available to all low-income women, as it is in all other developed countries).

    What Americans can boast of is a slavish, evidence-be-damned devotion to the kind of supply-side thinking that has brought us to the current economic climate. And any questioning of this--any criticism of the notion that maybe, maybe, the reason government has "failed" (i.e. the VA) is not because it is inherently incapable, but rather, because it was set up to fail by the very factions who wanted to drown it in a bathtub to begin with (to quote Norquist)--is met with the same, tired, wah-wah-we-must-not-dilute-the-talent-pool arguments you can hear on CNBC when they're discussing cutting bonus pay to billionaire bankers.

    Underfund, under-staff, and undercut (deregulate) any agency, while keeping its workload constant (or, as with the FDA and the Consumer Product Safety Commission, increase its workload and concomitant pressure dramatically), and the results are easy to predict: output will suffer proportionately.

    That's why my inlaws waited all day at the VA: there were only a handful of doctors and nurses and roomfuls of patients needing, and deserving, care. At least there weren't any cockroaches running around the floor, though, as there were at Walter Reed when my friend helped break the WaPo story about that disgraceful situation.

    If healthcare is so great in other places where the nanny state pays for everything, then why do people come to Houston every day for care?

    They also go to Sweden, Denmark, France, and--gasp--England for specialized treatments, surgeries, and studies. People who live in countries where the rich are rich and everyone else can drop dead for all the government cares--not what one would call "developed" or "civilized" countries, in other words--are able to travel to places like Houston (and Sweden, Denmark, etc. etc.) and pay.

    Just because it is available cheaper in other parts of the world does not mean it is better - I can get a boob job on the cheap in Brazil, but I have a better chance of dying from complications there too.

    RAH RAH America! We may not be the slimmest, the oldest, or the healthiest bunch in the world--and our healthcare costs may well bankrupt you if you get sick--but hey, we look out for the nation's enhanced breasts.

  8. Dear Dr. Shadowfax:

    Both the article and your comments are misguided -- and, in the case of the article, I would even say "disingenuous".

    Others have responded to some aspects, though perhaps with more annoyance than is warranted; I would just like to mention that the Hardward 2005 study by Himmelstein at al. has been thoroughly debunked (for one such example, see http://content.healthaffairs.org/cgi/content/full/25/2/w74).

    I wonder: How many of those who go bankrupt with $1000 or more over two years in medical costs (that is Himmelstein's definition of a bankruptcy due to medical expenses) bought a plasma TV, a shiny car, or something else that was either unnecessary or unnecessarily expensive?

    Yours faithfully,

  9. I read the article, SF. Thanks for providing the link.

  10. Catron -- I was wondering when you'd show up. I was actually getting worried about you....

    As for the bankruptcy study, I plead ignorance. I'm too tired to look it up now, so I'll concede the point (for now...)

    J-Ro -- good point about the illegals and the uninsured. Not living down that way, I tend to forget.

    LitBrit -- WOLVERINES!!! Ha ha ha.

  11. Infant mortality and life expectancy are directly related, and both are also directly related to the large illegal alien and other non-Asian minority populations in our huge country compared with tiny little homogeneous (and heavily taxed) places like Sweden and Denmark.

    So yeah, disingenuous is right.

  12. I just did a little looking around on the internet. Folks commenting seem pretty intent on blamming an increase in infant mortality on illegal immigrants. This isn't born out by the facts ( http://www.statehealthfacts.org/profileind.jsp?cat=2&sub=13&rgn=31 ) Black, non-hispanics have the highest infant mortality rate of all groups in the country. Hispanics and whites have an equiviliant infant mortality rate.

    In New Hampshire, we have none of the diversity issues nor do we have an "illegal immigrant" problem that exists in other areas of the country. We also don't have the levels of obesity and diabetes that is faced in other areas of the country. Our per capita spending for health care is lower (see the Dartmouth Atlas). Our infant mortality rate while below the US is in line with the EU. Sound good? I don't think so, we have a fairly homogenous population unlike the UK, France and Germany. So we can do just as well, with none of the other issues that can contribute to an increase in infant mortality that those countries face.

    So yes, we do have issues in this country with healthcare and we pay way too much for it. It's not caused by illegal immigrants. It's caused by us not having the political will to do what we know works. It works to make universal access to healthcare a reality. It has been shown country by country over the course of the last half century.

    Illegal immigrants are just the latest "straw-man" in the argument on universal coverage. What I really wonder is what is the real fear of folks who are so against it. Being against giving healthcare is like being against mom and apple pie. Why is it bad to give universal access? Whether I pay for your health care through my taxes or through my insurance policy which needs to pay my doctor more so that my doctor can give charitable care, I'm still paying. Why not just be honest about it and not leave the charitable care to the hearts and minds of those running healthcare organizations? The hospital I work for gives away 22-25% of it's care in charitable care. Using that percentage, the cost to ALL of could decrease by 22-25% and we would all receive the same services that we do now if there was universal coverage. Universal coverage makes more sense to me than this patchwork system. Frankly, TX setting the standard for medicaid elgibility to where you can't afford to live, let alone eat and still not be elgible is horrible.

    Again, why blame illegal immigrants? Why not just put the blame where it belongs -- with you and me.

  13. I just did a little more looking. Texas and California (definately two states that bear the brunt of illegal immigration) have lower infant mortality rates than the nation.

    Washinton DC, Mississippi, Louisiana, Alabama and Delaware are the states with the highest infant mortality rates. Doesn't look like illegal immigration plays a role in infant mortality.

    Who should the next straw man be?

  14. Note: I was not "blaming" illegal immigration - I was just pointing out that there are states where it IS a problem, and as such, that should be considered when looking at our statistics, and it sure as HELL should be considered when The One and his minions start trying to determine how much crappy healthcare Americans will be allotted each year by the Omnipotent Government.

    Yet Americans are not enjoying longer lives; they do not have easier access (or, for some, any access at all) to the preventive care that demonstrably improves quality of life as well as lowers healthcare costs over a lifetime by identifying and addressing problems (i.e. obesity) and progressive illnesses early on; and they cannot boast of anything close to a low infant mortality rate (a statistic that dramatically changes when free prenatal and neonatal care is made available to all low-income women, as it is in all other developed countries).

    The quote above assumes that all over America, people would RUSH to avail themselves of preventive care if it were made available by the good graces of our most kind and benevolent Government. Read these medical blogs - right now, people who ALREADY pay nothing for healthcare take rides in ambulances for critical items such as broken toenails, complain because they aren't given three hots and a cot the minute they roll up at a hospital with their hangnail, and fail to take any sort of personal responsibility whatsoever for their own wellbeing going forward. Why should they? 9-1-1 and an ambulance is just a call on an expensive cell phone away. How is universal healthcare going to fix that?

    http://www.cdc.gov/nchs/data/databriefs/db09.htm : An excellent study on infant mortality rates in the US - interestingly enough, premature births and the problems associated therewith seem to have the most impact on that number. We have a very high percentage of preterm and early preterm births in the US. Why? Perhaps fertility treatments and multiple births – which are NOT free – are skewing that number. What that number seems to suggest, ironically enough, is that our advanced medical techniques may be contributing to this high mortality rate. How, exactly, will universal healthcare change this scenario?

    Bottom line, you can offer free prenatal care for pregnant moms, and can offer nutrition classes and free exercise classes to fight obesity, but unless you plan on making these mandatory somehow, they will fail. This is America - not a military junta. You can't force people to use these services. What are you going to do, have the cops go into some fat guy's house at gunpoint, yelling "Drop the cheetos and get your ass off the couch! It's exercise time, bitch!" and drag him off to the gym? How do you plan to use universal healthcare to stop obesity and diabetes and all the other lifestyle related illnesses? Forty treadmills and tofu in every pot? I am so sure that access to free prenatal care will make some pregnant crackhead immediately stop using and start taking her prenatal vitamins. I appreciate the compassion behind the thoughts of healthcare for all, but that is assuming that the "all" will make the most of it to improve their wellbeing.

    Make fun of me if you will, but I still say that the medical care in the United States IS the best in the world. Houston boasts the largest medical complex in the world, with doctors (De Bakey, Cooley) who are known internationally as pioneers and the best in their fields – and that is just one city. From MD Anderson to the Mayo Clinic – no other country can match the US. I am not saying the US is the ONLY place – it is just the best place.

    And for the record? I used plastic surgery as an example because of the “nip/tuck vacation to Brazil” trend that has been in the news so much lately, unfortunately for the bad outcomes associated therewith. Two celebrities lately have had a mom die and a wife become critically ill from such adventures. So yeah, medical care may be cheaper elsewhere – but it may come with a higher cost in the end.

    LitBrit – you are from England, and are obviously a fan of their government funded system. But what about the long waits we read about for routine treatments in England and in Canada, and the private hospitals in those countries that will provide those same treatments with no wait, but at a high financial price? I guess the system is still not perfect, and those that have still get and those that don’t have still don’t get. Those doctors have found a way to make money – heaven forbid – what makes you think that doctors in the US won’t do the same – start private practices and quit working at public facilities? Then you have my public school scenario all over again – unqualified, unmotivated folks in charge of our nation’s healthcare.


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