Insurance 101 question

[Robert Toy]

Case 1:
A person with a pre-existing medical condition is either denied medical insurance coverage, cancelled, or is charged higher than average premiums.

Reason: The pay-out is higher than the average, or the policy limits have been reached .

Somehow the current feeling being this is an unfair practice.

Case 2:
A person who because of an existing medical condition (example diabetes) has blacked out while behind the wheel of his car and crashed.

The driver’s policy (paid premiums) covered $20,000 per accident and a $5,000 deductable, should the insurance company pay more than $20,000 with no deductable?

Does the insurance company have the right to cancel the policy; increase premiums or deny future coverage?

Why is one case considered unacceptable and the other not?

[backslashbaby]

You don't have to drive. You need medical care.

That doesn't mean the particular insurance company needs to remedy that situation. But there needs to be a remedy.

[CACTUSWENDY]

I'm not sure....but when I took out my car insurance they never asked if I had any pre-existing conditions. They are to pay for any car damages that I have covered on my policy. Of course, I have never read the fine print.

[Robert Toy]

You don't have to drive. You need medical care.

That doesn't mean the particular insurance company needs to remedy that situation. But there needs to be a remedy.
So the insurance companies should be held responsible for providing free medical care?

[Don]

Well, somebody has to be held responsible, Robert. After all, free medical care isn't free, you know. Somebody has to pay for it.



Oh, wait...

[Brandi636]

Nobody NEEDS to drive, but do they do need medical care. This should be something provided to taxes, like other basic necessities. It shouldn't depend on someone's income or job. Every other developed country has figured it out. I don't know why something as lackluster as the public option is so controversial here. I for one have perfectly adequate health insurance, but I've never really had to use it. As of right now, I'm profitable to them, but what happens if I develop some condition? The whole idea of health care as a business is a joke. My health should not be dependent on someone else's bottom line.

[backslashbaby]

Quote:
<TABLE cellSpacing=0 cellPadding=6 width="100%" border=0><TBODY><TR><TD class=alt2 style="BORDER-RIGHT: 1px inset; BORDER-TOP: 1px inset; BORDER-LEFT: 1px inset; BORDER-BOTTOM: 1px inset">Originally Posted by backslashbaby http://www.absolutewrite.com/forums/images/buttons/viewpost.gif (http://www.absolutewrite.com/forums/showthread.php?p=3936555#post3936555)
You don't have to drive. You need medical care.

That doesn't mean the particular insurance company needs to remedy that situation. But there needs to be a remedy.
</TD></TR></TBODY></TABLE>

So the insurance companies should be held responsible for providing free medical care?

That's almost the exact opposite of what I said, so the 'so' confuses me.

I'm saying that health care insurers can be strictly capitalistic businesses, yes, and that makes a fair amount of sense as one option for the populace, and a lot of sense as a business.

Unfortunately, the ethics of the entire situation changes if they are too many people's only option. No, they don't have to remedy that. But someone/something will if enough people are dissatisfied with them.

~ irony alert ~ Charity groups that used to go from the US to aid 3rd world countries are doing that work for our own people now, for instance. Not a healthcare solution we should be proud of, but my hat is off to those docs for helping out.

[Robert Toy]

Quote:
<TABLE border=0 cellSpacing=0 cellPadding=6 width="100%"><TBODY><TR><TD style="BORDER-BOTTOM: 1px inset; BORDER-LEFT: 1px inset; BORDER-TOP: 1px inset; BORDER-RIGHT: 1px inset" class=alt2>Originally Posted by backslashbaby http://www.absolutewrite.com/forums/images/buttons/viewpost.gif (http://www.absolutewrite.com/forums/showthread.php?p=3936555#post3936555)
You don't have to drive. You need medical care.

That doesn't mean the particular insurance company needs to remedy that situation. But there needs to be a remedy.

</TD></TR></TBODY></TABLE>



That's almost the exact opposite of what I said, so the 'so' confuses me.

I'm saying that health care insurers can be strictly capitalistic businesses, yes, and that makes a fair amount of sense as one option for the populace, and a lot of sense as a business.

Unfortunately, the ethics of the entire situation changes if they are too many people's only option. No, they don't have to remedy that. But someone/something will if enough people are dissatisfied with them.

~ irony alert ~ Charity groups that used to go from the US to aid 3rd world countries are doing that work for our own people now, for instance. Not a healthcare solution we should be proud of, but my hat is off to those docs for helping out.
Sorry, the "so" was a bit of unnecessary snark - apologize

[backslashbaby]

No problem :D I am not always clear, but my posts are usually wordy enough without shooting for complete clarity ;)

[astonwest]

Obviously, people who claim this "don't NEED to drive" idea have never lived outside of an urban area where employment is within walking distance of your apartment...when your employer is located outside of town, and no feasible public transportation options exist, you definitely do need to drive.

[benbradley]

Nobody NEEDS to drive, but do they do need medical care. This should be something provided to taxes, like other basic necessities.
Like food and shelter?
It shouldn't depend on someone's income or job. Every other developed country has figured it out. I don't know why something as lackluster as the public option is so controversial here. I for one have perfectly adequate health insurance, but I've never really had to use it. As of right now, I'm profitable to them, but what happens if I develop some condition? The whole idea of health care as a business is a joke. My health should not be dependent on someone else's bottom line.
Yeah, why should doctors who spent a decade of their adult lives studying for the field and who have huge school loans to pay back, why should they charge for their services?

[LaceWing]

Yeah, why should doctors who spent a decade of their adult lives studying for the field and who have huge school loans to pay back, why should they charge for their services?


What I got from Brandi's post concerns the public option question, not whether doctors should be paid.

[Brandi636]

I'm not against doctors charging for their services. I just don't think it's fair to deny people health services because they can't afford it.

[Brandi636]

Obviously, people who claim this "don't NEED to drive" idea have never lived outside of an urban area where employment is within walking distance of your apartment...when your employer is located outside of town, and no feasible public transportation options exist, you definitely do need to drive.

That wasn't really what I meant. My work is located in the middle of a field with no access to public transportation (though they did put up bike racks to appear "green"), so obviously I "need" to drive to get there. I just meant it's not life or death.

[Christine N.]

You labor under the assumption that people can live without healthcare. But I get your point, sort of.

Health "insurance", truly insurance, is out to make a buck. When patient A becomes too expensive, they drop him. However, the feeling is nowandays that insurance co's are greedy bastards who put money above human life.

Now, in NJ, we have all these rules about how much insurance you must carry, even if you DON'T have medical coverage through your employer or whatnot. So, theoretically, if I were in an accident like patient B, they'd cover me according to my policy and then my premium would go up. If this were my second or third such accident, they'd probably drop me. And then whatever my car insurance didn't cover, my healthcare coverage would.

The problem lies in the insistence in calling what we have health 'insurance'. Unless you have just major medical, you've got managed care, healthcare 'coverage', not really 'insurance.'

[astonwest]

I just meant it's not life or death.Unless, of course, your life depends on having insurance coverage, and your insurance is dependent on having your job which you need to drive to.
;)

[GeorgeK]

The worst offenders that I've seen were scams disguised as insurance, where "CANCER INSURANCE POLICY" was emblazoned across the top of the page. Then in wording that some doctors and lawyers might have trouble deciphering, the policy began to dissallow everything. If you had had a skin cancer taken off twenty years prior, then they won't pay for treatments for unrelated kidney cancer now (this was in the late 90's), or they'd deny inpatient care for radical surgeries, claiming that they should be outpatient for a radical prostatecomy. Then, when once in a while their criteria didn't exclude something, their maximum payout was a pittence compared to even a month's worth of premiums.

Granted those were the worst that I saw, but the line blurs very quickly when reportedly reputable companies can take years to pay a claim and automatically deny everything that comes across their desk on a Thursday or Friday, and drag things out so that people who need their medications will pay out of pocket just to survive. The insurance companies are just legallized bookies, taking odds that you won't get sick. Just like the bookies on the street, they will try to scam you.

[ricetalks]

So the insurance companies should be held responsible for providing free medical care?
Isn't that what you're suppose to pay insurance for? I think the problem with "pre-existing condition" is how that seems to be applied to everything immediately upon filing any claim. A little charade.

[ricetalks]

Nobody NEEDS to drive, but do they do need medical care. This should be something provided to taxes, like other basic necessities. It shouldn't depend on someone's income or job. Every other developed country has figured it out. I don't know why something as lackluster as the public option is so controversial here. I for one have perfectly adequate health insurance, but I've never really had to use it. As of right now, I'm profitable to them, but what happens if I develop some condition? The whole idea of health care as a business is a joke. My health should not be dependent on someone else's bottom line.

So how do you really know?

[clevernamehere]

What socialized medicine does and what US insurance companies used to do is pool everyone together and figure out a fair rate. That type of pooling assumes that we are all going to be low cost twenty somethings at one point and high cost 80 year olds at another so it all works out in the end.

But in recent years insurance companies have begun kicking out everyone they can, increasing their profits and leaving a huge pool of people who cannot get insurance and guess where they end up? That's right, the public system! And they usually don't end up there until they are very, very sick and therefore more expensive. 30 years ago, the majority of people paid for insurance and a small proportion of the working poor ended up needing public assistance. But insurance companies have been allowed latitude that has basically screwed the tax payer in the end because we don't just let people die in the street.

The federal government has regulated business for over a 100 years without turning us all communist. The current situation is no different than busting the sugar trust or breaking up Ma Bell.

[dgiharris]

IMHO, the basic problem in America is that the HealthCare industry is run for profit. That is the fundamental flaw. Any attempt to fix it without addressing that fundamental flaw is doomed to failure.

Now, does running it as a non-profit mean that doctors work for peanuts? No.

*sigh*

I think it would be interesting to see the economics of the HealthCare industry laid out.

Education costs, facility costs, hospital utilization, salaries,
vs.
Patient costs, Emergency rooms cost, Medicare, Medicaide
vs
R&D costs, government subsidies
vs.
Costs and Profits from drug industry

I have a feeling that if a open minded group of experts got together, looked at the overall costs of everything that we can easily work something out.

For instance. What about a hybrid akin to the US Postal Service vs. Fed Ex vs. UPS.

The USPS is for the average American and we are happy with them. But on those rare occasions when we need something super special, we can choose to go to Fed Ex or UPS and pay more.

Why not something like that for Health Care?

What about institutions where the government funds your education so then you owe nothing in student loans, and in exchange you work 10 yrs (with decent salary as compared to your peers) in a government run hospital? The military uses this model.

*sigh*

But the battlelines have been drawn. We aren't interested in a real solution if it differs from the dogma or our respectives parties.

Mel...

[dmytryp]

IMHO, the basic problem in America is that the HealthCare industry is run for profit. That is the fundamental flaw. Any attempt to fix it without addressing that fundamental flaw is doomed to failure.


Without going into the debate which system is better (I am actually very happy with our health care system, though I am not entirely sure it can be transferred to the US), I think your point is flawed.

I think there is absolutely no difference between running something that has to adhere to a certain budget and running something for profit. After all, what does running for profit means? It means that the management sets a target profit margin and enacts policies based on this. Which in turn translates into a budget. It is exactly the same as running on a given budget. The only difference is that you have a line that says, "this amount of money out of the budget needs to be a profit."

Your point would be correct in a world with unlimited resources. In the end both systems come down to monetary constraints. We have a universal health care system. Does that mean everything is covered? No (we have almost no dental coverage, for example). There are battles about new drugs to be included into the coverage. There are always complaints that private hospitals are better than the government ones. That there is inequality. Etc. Etc. Basically, to a large extent the arguments are similar to what I am hearing here, even though we have a universal coverage.

[Bartholomew]

PROFIT is a word that people occasionally try to make dirty.

Money is the grease that keeps the nation going. The question should, and is not, about removing money from the equation. Its about whether the money is being used well.

Hint: it isn't.

[GeorgeK]

Now, does running it as a non-profit mean that doctors work for peanuts? No.

*sigh*


They already are if you look at the business model. After all the government mandated discounts, the massively rising malpractice premiums, the cost of paying staff and rent, corporate taxes, (and this is about ten years ago, I'm sure it's worse now), the Dr actually takes home a gross paycheck (before income taxes) of 15 cents for every dollar billed.

Bill 100 of which the office actually ends up getting 60 if you are doing well, then 3/4 of that goes to pay office etc. The doc gets 15cents and then has to pay personal income taxes

Education costs


I was in med school in the 80's and the figures were staggering then. Costs have skyrocketted since, but I was told then that the national average was that a medical student upon receiving their doctoral degree was a quarter million in debt. I went to a good state school in a bodunk area where costs were lower. For my class the average was 150,000. I got through the cheapest. I took a year to save up money so that I could avoid the high interest loans that went toward living expenses and the first year's tuition because you won't have much time to work while in med school. I'd eat off the same pot of chili for a week made with the cheapest cuts, (then that was beef hearts usually). I'd make mackerel meat loaf. I'd take a can of green beans and an apple with me to school as lunch. My food buget was 15$ per week. My final bill was just under 60 grand.

As a resident we were payed far less than minimum wage because we were salaried. It also depended upon what specialty you were in. When I was a 5th year chief in Urology, the Family practice intern made more than me and didn't have the kind of call schedule that I did. Most had to take out more loans during residency for living expenses while their school loans were accruing interest while in deferrment. It was said then that the average surgeon was still paying off school loans at the age of 45, and by then they have mortgages, car payments, often alimony, kids in school etc

I haven't seen any detailed figures since then, and since which medicare reimburesments have been steadily falling while costs have gone up. I think seeing the figures is scaring people away from med school. The vast majority of money in health care ends up going to the non-doctor people in suits (Insurance execs, hospital CEO's, bankers, and middlemen)


What about institutions where the government funds your education so then you owe nothing in student loans, and in exchange you work 10 yrs (with decent salary as compared to your peers) in a government run hospital? The military uses this model.


I'm sure that the resistence to something like that would not come from the incoming students and you'd be easily able to fill your staff with existing physicians if they could trade their existing balance of debt for 10 years service. I've proposed stuff like this before but politicians listen to campaign contributors, not logic.


*sigh*

But the battlelines have been drawn. We aren't interested in a real solution if it differs from the dogma or our respectives parties.

Mel...

[johnnysannie]

Case 1:
A person with a pre-existing medical condition is either denied medical insurance coverage, cancelled, or is charged higher than average premiums.

Reason: The pay-out is higher than the average, or the policy limits have been reached .

Somehow the current feeling being this is an unfair practice.

Case 2:
A person who because of an existing medical condition (example diabetes) has blacked out while behind the wheel of his car and crashed.

The driver’s policy (paid premiums) covered $20,000 per accident and a $5,000 deductable, should the insurance company pay more than $20,000 with no deductable?

Does the insurance company have the right to cancel the policy; increase premiums or deny future coverage?

Why is one case considered unacceptable and the other not?

Because they are not comparable for many reasons. To reject a diabetic for coverage simply because he or she is diabetic because a few diabetic patients might black out behind the wheel of a car and crash is ridiculous. Most diabetics keep their blood sugars well in check but they are too often penalized insurance wise because of their pre-existing condition.

People should have a right to health care, the SAME level and quality of health care regardless of race, religion, wealth, or pre-existing condition.

[dgiharris]

I think there is absolutely no difference between running something that has to adhere to a certain budget and running something for profit.

Actually, I couldn't disagreee with you more on this.

In the military, we were essentially a non-profit. What this means is that our mindset is COMPLETELY different from bean counters in a profit center. Our focus was MISSION FIRST and as a result, the US military in many ways is an example of what is best in US government policies, procedures, etc.

However, when you are a profit center your focus is PROFIT FIRST. In the US, this translates to Insurance companies screwing their clients in more ways than a X-rated porno.

Now, I'm a firm believer in capitalism however after careful thought, the reason why this model* should not be applied for health care is simple, the invisible hand doesn't do well with extremes. (*model needs some adjusting in order to work with health care, see my reason solution below)

The extreme in health care is human life. How much are you willing to pay to live? There is no ceiling on that and that screws up the Capitalistic model IMHO.

But since we are a moral society we believe that in an 'emergency' you are entitled to health care, so this translates into scores of people going to the emergency room and i've got to believe those costs are MORE than treating the root cause of a problem BEFORE it becomes an emergency.

The more I think about this issue, the more I'm convinced that we need a hybrid model. Government run healthcare for the masses and a private healthcare industry for those that wish to pay. Just like the USPS and Fed Ex. This model can and does work!

THe military is a great model for government run healthcare. All the doctors in a military hospital are military-government professionals. The government paid for their education, in turn, they owe 10 yrs of service. After 10 yrs, I think 40% - 60% elect to stay because they don't have to worry about malpractice insurance and with the tax breaks (and no threat of being sued) their salaries are comparable to their peers.

In a nutshell, what we have now just is not working. We need something new and I believe if you look at all the cost, all the doctor issues, I bet you my idea would work wonders.

How many doctors would love to work without having to pay malpractice insurance?

How many doctors would love to finish school without any debt?

With my idea, you still have your profit hosptitals. It is a win - win. Show me where i'm wrong?

Mel...

[Robert Toy]

Because they are not comparable for many reasons. To reject a diabetic for coverage simply because he or she is diabetic because a few diabetic patients might black out behind the wheel of a car and crash is ridiculous.

I only pulled examples of three states, I’m certain most if not all states can restrict or reject a diabetic from driving.

http://www.diabetes.org/advocacy-and-legalresources/discrimination/drivers/pvt-california.jsp
http://www.diabetes.org/advocacy-and-legalresources/discrimination/drivers/pvt-newyork.jsp
http://www.diabetes.org/advocacy-and-legalresources/discrimination/drivers/pvt-texas.jsp


People should have a right to health care, the SAME level and quality of health care regardless of race, religion, wealth, or pre-existing condition.
Like auto insurance you will get what you contracted and paid for, it cannot be the same for all.

[Don]

THe military is a great model for government run healthcare.
Cool. I'm gonna start a toilet-seat factory. At $600 each, I won't have to sell many.

[dmytryp]

Actually, I couldn't disagreee with you more on this.

In the military, we were essentially a non-profit. What this means is that our mindset is COMPLETELY different from bean counters in a profit center. Our focus was MISSION FIRST and as a result, the US military in many ways is an example of what is best in US government policies, procedures, etc.



Well, first I don't think you want to bring the military in favor of gov health care. Militaries are notorious for waste, inflexibility etc. But that's just me. And it doesn't have a lot to do with my point.

With regards to my point. Military (at least US military) for all intents and purposes has an unlimited budget. The budget is so huge that particular people don't feel the constraints. And this is why you get the attitude you describe. However, having been in the military that does have monetary constraints, I can tell you that this is relatively similar to being in an organisation that has to turn some kind of profit. This was especially obvious when we had drastic budget cuts. Projects got scrapped, operations went ahead without some support they might have had in previous years etc. etc.

Again, I am not saying that government run health care can't work. It obviously does work very well in many places (one of which is Israel -- well, it is not exactly government run, but pretty close). What I do say, that when there are real budget constraints, it is not much different than a company with a certain profit margin in mind.

[jennontheisland]

The more I think about this issue, the more I'm convinced that we need a hybrid model. Government run healthcare for the masses and a private healthcare industry for those that wish to pay. Just like the USPS and Fed Ex. This model can and does work!


This model is being vehemently opposed by many in Canada. Up here it's called a two tier system. And the main concern is that no doctor is going to want to work in the government run healthcare for the masses system when they could be lining their pockets charging anything they want in the private healthcare industry.

That said, I believe Iceland's system is two tiered (maybe another Scandanavian country or two as well) and seems to work for them.

And I wanna know what kind of porno isn't X-rated.

[dmytryp]

This model is being vehemently opposed by many in Canada. Up here it's called a two tier system. And the main concern is that no doctor is going to want to work in the government run healthcare for the masses system when they could be lining their pockets charging anything they want in the private healthcare industry.

That said, I believe Iceland's system is two tiered (maybe another Scandanavian country or two as well) and seems to work for them.

And I wanna know what kind of porno isn't X-rated.
We have doctors that work by day in governent run hospitals and in the evening go to their private practice in a private hospital. It opens up all kinds of problems, but mostly still works. In the end, it all depends on how the system is devised.

[LaceWing]

This model is being vehemently opposed by many in Canada. Up here it's called a two tier system. And the main concern is that no doctor is going to want to work in the government run healthcare for the masses system when they could be lining their pockets charging anything they want in the private healthcare industry.


Which is why I'm very enthused about the example set by the Mayo Clinic. Doctors pool their income and the hospitals pay them salaries.

If the two-tiered system is pushed far enough, only doctors themselves would get the very best care.

[GeorgeK]

With regards to my point. Military (at least US military) for all intents and purposes has an unlimited budget..

Over the years, ranging from a position as a tech to an attending MD I've worked in an active military hospital, a VA and at least a dozen civilian hospitals, some "for profit" and some "not for profit". Overall they all had about the same degree of problems, just a different set of problems (well except for the VA, it was so swamped that scheduling anything was a nightmare). The active military hospital was if anything a bit better about not wasting resources than most of the rest. I think a big part of it is who is at the top of the command. If your CEO/Commander is a golddigger or a frivolous spender then there are going to be budget problems.

[StephanieFox]

Like food and shelter?

Yeah, why should doctors who spent a decade of their adult lives studying for the field and who have huge school loans to pay back, why should they charge for their services?

My dad was a doctor – a surgeon, actually – who practiced small-town medicine from the 1950s through the 1990s. He was appalled by the costs of health care in his later years. He never turned away someone who needed his help, even if they couldn't pay. He told me that about 30 percent of his patients never paid him because they were too poor to do so. Despite this, he brought home a pretty good income. We had a nice house, nice clothes and nice cars.

He was originally against what he called 'socialized medicine' but changed his mind as the price of medical care sky rocked. Everyone, he felt, should have access to quality health care. By the time he died in the late 1990s, he was fighting for this, especially for veterans.

So to answer your question – yes, doctors should get paid. But, people shouldn't have to be sick or die because they can't afford good health care. It doesn't have to be one or the other. That's what the health care reform debate is really all about.

[astonwest]

With regards to my point. Military (at least US military) for all intents and purposes has an unlimited budget.
If that was the case, there wouldn't be such a push to slash programs like the F-22, etc. If they could spend as much as they wanted, they would have leased new air tankers several years back, instead of going through several rounds (with no end in sight) of contracting bids for a full purchase.