hearts and minds

August 6, 2006

Winning less expensive, better quality Health Care for the U.S. (part 2)

Filed under: Health care crisis,legalized bribery — Hearts & Minds @ 8:49 am

The solution to the problems I outlined in Part I that confront Americans regarding our medical care system is simple and proven. We need Universal National Health Insurance that is:

(1) Universal – all Americans would be fully and uniformly covered; no tiers for “commoners”, the elite, and the uninsured.
(2) Portable – coverage stays the same regardless of changes in employment, residence, age or marital status.
(3) Accessible – medical services would be covered from any provider anywhere…no “preferred” providers.
(4) Comprehensive – no denial of care for “pre-existing” conditions, no “pre-approval” of treatment, no exclusions, no cut-off ceilings.
(5) Publicly administered – Oversight of effectiveness would be provided by public scrutiny, the democratic process and medical professional review, rather than by corporate CEOs, accountants and their desire to maximize profits, dominate the market and rake in millions in bonuses, stock options, and golden parachutes.

And we need, we must have, medical care providers that can retain the commitment and the ability to serve, first and foremost, the traditions and ethical standards of their ancient and honorable profession.

The free-wheeling insurance and HMO giants have transformed U.S. health care because their arm-twisting drives providers (the traditional private practice physicians and the independent community based hospitals directed largely by practicing doctors) into takeovers by for-profit corporations and mergers into mega-corporations which then wrestle with the insurance companies for slices of the billions of health care dollars. The more health care dollars there are, the bigger the pie. The fewer of those dollars actually spent on health care, the bigger the profit margins. The consequences to us of this development in health care are severe, and adverse to cost containment, quality of care, and choice in America.

All modern industrialized nations in the world…except the U.S.…have Universal National Health Care. And U.S spending on health care per person is twice that of all other modern industrialized nations. Switzerland, our nearest competitor in big spending, puts out 65 cents for every dollar we spend per capita. At the time that Universal National Health Care was first mandated in Canada, their costs were the same as costs in the U.S. But by 1995, Canada’s total health expenditures per person were only 55% of what America was spending. These countries health care costs are way less than ours because their systems are publicly funded, universal and comprehensive. There are no legions of what we used to call paper shufflers, no determining eligibility, no chasing after payments from impoverished patients, no prior approval for medical treatment, no endless variety of complicated forms and procedures depending on which HMO or insurer, which species and permutation of health care “Plan” applies. Doctors and nurses can spend all their time on patient care, much less of their time on paperwork and none being monitored or struggling to understand and comply with payment and treatment directives from a myriad of insurers. Canadian hospitals spend 30% less on administrative costs than do U.S. hospitals.

The American employment-based multiple-private-insurer system, full of dangerous gaps and loopholes, leaves American business holding the bag. A small business with few employees has no leverage negotiating with the insurers. To provide employees with truly good (check the fine print) coverage places the business at a severe disadvantage with the competitor who slyly provides junk insurance or none at all. Associations and big corporations are also caught in the crunch. Fifteen years ago, Chrysler spent $500 more to build a car in Detroit than it did to build one across the bridge in Ontario because of the cost difference of health care. That’s another excuse for jobs to migrate overseas. And it’s only gotten worse. Canada spends 10% of GDP on health care costs while the U.S. spends 14%.

Quality of care is secondary to the profit motive in the U.S. system. All countries ration medical care. In Canada this rationing depends on urgency of medical need. In the U.S. it depends on (a) whether your particular insurance coverage even allows you to get in a particular service line, and (b) whether you can pay to jump to the head of the line. Managed care attempts to control costs by monitoring and controlling the treatment plans of physicians. But under Canada’s national universal plan, doctor’s clinical decisions are neither questioned nor monitored except by the College of Physicians and Surgeons. In Canada there are 25% more nurses working per capita than in the U.S. where providers rely heavily on untrained “aides” and “assistants” for patient care. After WWII the U.S. led the world in life expectancy. By 1997 American women ranked 20th among industrialized nations, American men ranked 22nd in life expectancy, and the U.S. ranked 24th in infant mortality. The thirteen page Canada Health Act enacted unanimously in 1984 also covers nursing home, home care, residential care, and ambulatory care as needed. Canadian elders receive four times as many home or nursing home care-giver visits as do American elders. Quality of medical care in a nation is not measured by what is procurable by the very wealthiest of individuals. It is measured by what is actually provided to all of the people.

Paradoxically, citizens in countries that have publicly financed Universal National Health Insurance have much more individual choice in their medical care than do we Americans with our privatized, for-profit, multiple-insurers, employer-based system. Most people in the U.S. have a “choice” of only one “Plan”, that chosen by their employer. Preferred provider lists and required pre-approval restrict us to specialists, hospitals and treatment plans chosen neither by us nor by our doctor. If the HMO takes a hike, if our job changes or if the boss decides to sign a different contract, we may have to change our family doctor and get a whole new preferred provider list. Universal National Health Insurance lets you chose any doctor you want; the doctor and patient can refer to any specialist or hospital; and there is no pre-approval required of your doctors treatment plan.

A Gallup poll found that 96% of Canadians prefer their health care system to the U.S. model. Despite all the misinformation here, a majority of Americans also prefer Universal National Health Care. And regarding trust; a 1997 public poll published in the New England Journal of Medicine found that “health insurers and managed care companies were ranked 2nd & 3rd from the bottom, just above the tobacco industry”. Let’s get the health care system we need, now, and stop the corporations, with their obscene campaign “contributions”, that are getting rich off the present mess by derailing real reform.

February, 2003


    I’m self-employed, which is to say, I’m a contractor, a communications specialist. Companies seem to appreciate my skills enough to pay me a livable wage, but they do not seem to value me enough to offer me a position that includes healthcare benefits or any form of retirement support. Alas, the new-world (corporate American) paradigm, which more resembles the old-world paradigm where it’s truly every man for himself…

    I have to buy my own healthcare plan for myself and my family (wife and two small children). I started out with Unicare Health, and the first time I tried to use the “benefits,” Unicare denied my claim. This was supposed to be a wellness visit (yearly medical checkup) that I had definitely and absolutely paid for in my plan. My doctor’s office was so accustomed to the slimy tricks of Unicare Health that they routinely called this provider to verify coverage before patients left their office. Not surprisingly (for them), Unicare was telling them that I would not be covered for that visit. I called my insurance broker and immediately cancelled my Unicare plan. I then opened a new account with Assurant Healthcare. I opted for a high-deductible, crappy coverage plan (no dental) that supposedly allows my family and I to visit a doctor four times per year for whatever reason. I visited my doctor for some irritation I was experiencing (a male-related syndrome that occurs for all men as they get older—I am nearly 50). A week after my visit, Assurant started harassing me with forms that required me to release my medical records to them (which I had already agreed to do during enrollment), and I was to list the last three times I visited a doctor (also which I had already done during the enrollment), and list my last three visits to a pharmacy. My claim was summarily denied pending this information. Assurant want to make sure that this was not a “pre-existing” condition. I had not ever seen a doctor for the symptoms that had prompted me to go for this most recent visit, so I know that Assurant will not find any legitimate reason to deny payment. But the fact that this is the treatment I and other customers must endure is immoral and criminal because they do not provide the services they are peddling. THE HEALTH INSURANCE INDUSTRY IS THE HUGEST CRIMINAL ORGANIZATION IN THIS COUNTRY TODAY, AND IT MUST BE STOPPED.

    Comment by Peter — January 29, 2007 @ 11:16 am | Reply

  2. The stories begin. I was diagnosed with an incurable, very aggressive case of a disabling, chronic illness when I was 20 years old, but I was employed full-time with benefits, or not. A couple months later, the company I worked for was “bought-out.” A father sold it to his son. The “new” owner decided to change insurance companies. Unknown to the employees, time lapsed between insurance coverage and the new insurance company decided that myself and another employee would not be accepted for health coverage due to pre-existing conditions. This could only be done legally because the insurance was allowed to lapse between the two insurers. A cost savings for both my employer and the insurance company. I was allowed a voluntary layoff in order to find a job with insurance.

    Next job, the insurance would not cover my pre-existing condition for 6 months. I grew sicker and could no longer work. Here comes Medicaid. Medicaid would not approve coverage for my treatment. I took them to court, lost, but Medicaid soon reversed their policy regarding my treatment. Medicare soon joined in, but Medicare didn’t contribute barely to the cost of my treatment.

    A few years down the road, I was granted a Fellowship for Graduate School and thereby received State Employee Benefits. Blue Cross/Blue Shield – excellent, but a few years later, 6 weeks in-patient rehab, and 2 knee replacements later, in addition to my “normal” treatment, I was dangerously close to their lifetime maximum. No matter, I suppose, there was a 3-year threshhold on fellowships.

    Thankfully, I landed my dream job at a health care-based institution, measuring the effectiveness of a publicly-funded, community health care program. The institution would not cover one of my treatments. I appealed the decision to no avail. My vision was so effected, I had to leave my job. Before I left, a physician working in my office suggested that I see a therapist to learn how to deal with my terrible disease. I tried to sue, however, the institution is self-insured and as such largely protected from such frivolous law suits.

    Back to Medicaid. Are you having fun yet? I enjoyed the Medicaid Purchase Plan, where I paid a monetary premium for Medicaid while I worked a part-time job (I apparently was not poor enough, though I would qualify for other services based on low incomes). When I no longer had that part-time job, I was told that I would have to pay several hundred dollars every six months in deductibles for Medicaid – more than when I had been while working. I guess some people call this a work incentive. I might have a few other words to describe it.

    Of course, I had a hard time finding a job, but finally landed part-time one that pays $9/hour, I think it may require a high school diploma, AND I can keep Medicaid for $75 a month. This is all accompanied by Medicaid kicking people out of their system for prescription coverage and requiring them to use Medicare Part D. Medicare Part D uses private insurance companies to administer coverage. Several of my prescriptions needed prior authorization or had to be changed to a different prescription because they didn’t have the “right” brand name.

    I think I may have touched on everything. Oh yes, I’m 36 years-old now. For some reason, employers are hesitant to hire me with full benefits.

    I forgot to add, I can’t find a dentist in the area who accepts Medicaid, any ideas?

    Comment by Melinda — April 26, 2007 @ 6:43 pm | Reply

  3. Just wanted to warn readers to NEVER purchase dental insurance (or any insurance) from Security Life Insurance Company of America (SLICA). They are swindlers and cheats. I have paid them at least $720 in premiums every year for the past four years. During that time, I never once used the “benefits.”

    Lo and behold, just a few weeks ago, one of my wisdom teeth got infected and I had to have it removed. I called the oral surgeon’s office and got an estimate for the procedure. I called SLICA with the estimate and I was told my benefits would cover 50% of the costs less a $50 deductible. The surgeon’s office even called them. At no point did any representative tell me that they would cover 50% only if they felt the fee was “reasonable.”

    So I got the procedure done — I couldn’t wait because of the infection and because I am taking the MD bar exam at the end of next month. The total amount for the procedure was $900. I paid $500! up front (800 * 50% = 400 + 100 for the laughing gas that was NOT covered under my plan = $500). I called the insurance company two weeks later to check on the status of the claim and they told me they would only pay $175 of the remaining $400 tab. HOW IN THE HELL IS THAT 50% OF THE COSTS?

    I was then informed that SLICA would cover 50% of what they miraculously decided was a reasonable charge for the procedure. So, in essence, when they tell you that you can go to whatever dentist you want, there is a HUGE CAVEAT that it is up to them whether to pay the claim. Basically, they want you to treat dentists and oral surgeons like car dealerships — bargain and wheel and deal for the best price — which I think is incredibly F*&K Stupid.

    Then, I was told I should have done a pre-estimate before the procedure. I countered that I did receive an estimate from the surgeon and that the customer service monkey (CSM) I spoke with told me it was alright, to which CSM #2 told me they do not provide estimates of reasonable service over the phone. You know why? Because it’s a crock of sh**. How exactly do they calculate what a reasonable fee is? Based on what? These determinations reek of arbitrariness and unfairness.

    I am incensed that I paid at least $2500 to this damn company for the past four years, never used the benefits until this one time and then they tell me they refuse to even cover a measley $400 (when I already paid $500 out-of-pocket).

    Long story short — avoid Security Life Insurance Company of America. Worst Dental Insurance Company EVER!

    Comment by JC — June 19, 2007 @ 4:13 pm | Reply

  4. […] don’t miss Part II of this essay, and the good news. (See Winning Less Expensive, Better Quality Health Care for the USA […]

    Pingback by Cost, Quality, and Choice in Health Care in the U.S. (part 1) « hearts and minds — July 12, 2008 @ 12:21 pm | Reply

  5. […] the growing health care crisis we have today, the simple, obvious, solution is to (belatedly) strengthen and expand Medicare and extend it, with no co-pays and no deductibles, […]

    Pingback by The Solution to the Health Care Crisis is Staring Us In The Face « hearts and minds — March 9, 2010 @ 5:06 pm | Reply

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