Private For Non-Profit Health Care - Possible?

[cadbrowser]

I am not sure if this topic belongs in SLAM or not, so if a mod deems it necessary to move, please do so.

In the US, as most of you are already aware there is a great disconnect between those that can afford healthcare and those that can't. Even then, the loopholes and stipulations of these programs can still cause a person to go bankrupt trying to save the life of their spouse from something like Cancer. It pains me to hear these stories, that one of the richest nations in the world can fail it's citizens so easily in the name of capitalism.

I'm not saying capitalism is bad. I just think it is wrong to profit off of someones suffering the way that Hospitals/Pharmaceuticals/Health Insurance companies do. It just doesn't seem ethical.

So, imagine if you will, a person. An average Joe that is on the lower end of the middle class wants to find a way to make it better. Could it be done?

What steps would this individual need to take to start a revolution?

How could a person start a non-profit healthcare system where:

1. Those that can afford coverage pay a small monthly fee. (Perhaps broken down by yearly income).
2. Those that can't afford it could still be covered.
3. Harsh negotiations with the companies that gouge the sick with outrageous prices (35000% mark up on Saline Bags - sterile salt water people)
4. Doctors, not employees of the Heath Care insurance, get to dictate how a person is treated for.
5. Everything is covered. No bullshit co-pays, drug tiers (other than internal in line with 3), limitations, etc.

I know there is more, a lot more, but lets get the ball going. I would like not to hear that it would "never work"; I want to know how it could be possible.

How could the revolutionist get started?

[Broomstick]

Some of the Blue Cross Blue Shield companies started as mutual non-for-profit companies long, long ago. It worked well for awhile, but as medical care became more complex and more could be done for severe injuries and illnesses the costs went up for the very sick/injured that had to do with the base cost of the technology and not about price-gouging. Then there is the price gouging. And a bunch of other factors that, I think, makes that model non-viable except on a national scale i.e. citizens pay taxes to fund government-sponsored universal health coverage.

[cadbrowser]

I am wondering what the timeline of that is Broomstick. I'll have to do some research on that. I'm going to take a wild guess that it became non-viable once Hospitals became for-profit and then legislation allowing price gouging by pharma.

It also depends on how much they were charging and how many members they had, right?

Hypothetical Case Study:
Non-Profit Insurance Company offers healthcare for a family (up to 4 members) for $100 a month for anyone making 35k to 45k per year. Lets assume for the sake of this hypothetical that this appeals to age groups 25 to 44, which according to the 2010 census is approximately 82 million. Would it be reasonable to assume that 10% of that population would sign up for said insurance?

If so, 8.2 million x $100 = $820 million per month = $9.84 billion per year.

Based on an initial scrub search on the internet, the average cost for an uninsured doctor's visit is $200. And it looks like overall (in all age categories)
in the US that the average person visits the doctor about 3 times a year.

So, if 8.2 million people visited the hospital 3 times a year at a cost of $200 per visit, then that = $4.92 Billion.

Can anyone argue that the remaining 4.92 Billion wouldn't be enough for overhead + non-average issues/visits?

I am not finding any quick and dirty amounts for Prescriptions spent per capita on an annual basis for that age group. That could be a difference as well.

[Bedlam]

Ultimately the problem isn't getting health cover for a part of the population which is generally healthy, everybody wants to insure them. It's getting insurance for people who are actually likely to claim more than they pay in which is the tricky bit. Insurance is really all about the healthy subsidising the sick on the grounds that they might be sick one day.

[Broomstick]

I am wondering what the timeline of that is Broomstick. I'll have to do some research on that. I'm going to take a wild guess that it became non-viable once Hospitals became for-profit and then legislation allowing price gouging by pharma. It also depends on how much they were charging and how many members they had, right?

Here is a link to some information you might find useful. The first company that is part of BCBS was founded in 1929. That was 13 years before penicillin become available to civilians. Costs were less because there was so much less that could be done. There were opiate painkillers, aspirin, a few specific treatments like quinine for malaria and insulin for diabetes, and surgery - but less sophisticated surgery than we perform today. No kidney dialysis. No organ transplants. No cancer chemotherapy. No open heart surgery. No limb re-attachment.

It's not just price gouging - we can do more, but all of those things have a cost. Some cost little, like antibiotics (usually). Some cost a lot. Some cost a lot for years.

I can tell you that it was 1994 when some of the BCBS companies went from non-profit to for-profit. It was not without controversy.

Non-Profit Insurance Company offers healthcare for a family (up to 4 members) for $100 a month for anyone making 35k to 45k per year. Lets assume for the sake of this hypothetical that this appeals to age groups 25 to 44, which according to the 2010 census is approximately 82 million. Would it be reasonable to assume that 10% of that population would sign up for said insurance?

Doesn't matter - that's far too low an income for a health insurance company.

Based on an initial scrub search on the internet, the average cost for an uninsured doctor's visit is $200. And it looks like overall (in all age categories)
in the US that the average person visits the doctor about 3 times a year.

So, if 8.2 million people visited the hospital 3 times a year at a cost of $200 per visit, then that = $4.92 Billion.

There is no hospital visit that costs only $200/occurance. That's for doctor's office visits. Hospital visits are at least an order of magnitude greater, often two, and can be considerably more than that.

Can anyone argue that the remaining 4.92 Billion wouldn't be enough for overhead + non-average issues/visits?

Yep. You're not only not counting the hospital visits in the $20k-70K range, you've completely overlooked the "million dollar" patients. A baby born at 6 months gestation,for example. Serious burn victim. Cancer. Organ transplant. Really bad trauma requiring multiple surgeries to repair bone and muscle and reconstruct parts of the body.

As an example,my spouse maxed out a Blue Cross policy in his 20's - I believe that one had a million dollar lifetime cap (this was back in the late 1970's when such things were still allowed). He lived nearly another 40 years after that, and easily racked up another half million over those years. And he was hardly the worst off of people, he went a couple of decades without needing significant care.

There are people whose medical costs top $100,000 every year, year after year.

Once upon a time I worked for the Blue Cross Blue Shield companies. I used to have access to a lot of financial rules and requirements for a company to retain membership in that group. I don't remember the exact numbers, and even if I did I couldn't divulge them, but you're lowballing the costs. I don't have the time and energy right now to delve into all this, but you have to figure out what percentage of that 10% of the population you expect to sign on to this is going to become high-dollar costs.

[bilateralrope]

Why do you want a privately run solution ?

[His Divine Shadow]

I'd like to quote the swedish high philosopher Åke Jävel, "it's better to blow things up than privatize them".

[Simon_Jester]

There are things that work better when they're privatized, usually in situations where privatization leads to more honest cost accounting and therefore cost control.

For example, the Soviet Union wound up gutting its Cold War economy to sustain its military in part because it didn't intelligently track how much all those tanks and planes and missiles cost to build. Privatizing the "make stuff for the military" industry would probably have been good for the USSR. Because the Soviet government could then have looked at a realistic cost assessment of "it takes umpty million rubles to build a tank, do we REALLY need another ten thousand of them?" And decided, y'know... they didn't actually need those tanks. They'd be okay, thanks.

But that doesn't work for health care, because almost nobody looks at the bill for chemotherapy or limb reattachment and says "nah, I can do without this, I'll be okay, thanks."

[Lord Revan]

There are things that work better when they're privatized, usually in situations where privatization leads to more honest cost accounting and therefore cost control.

For example, the Soviet Union wound up gutting its Cold War economy to sustain its military in part because it didn't intelligently track how much all those tanks and planes and missiles cost to build. Privatizing the "make stuff for the military" industry would probably have been good for the USSR. Because the Soviet government could then have looked at a realistic cost assessment of "it takes umpty million rubles to build a tank, do we REALLY need another ten thousand of them?" And decided, y'know... they didn't actually need those tanks. They'd be okay, thanks.

But that doesn't work for health care, because almost nobody looks at the bill for chemotherapy or limb reattachment and says "nah, I can do without this, I'll be okay, thanks."

the point about healthcare is really good, as the kind of healthcare you need for health functioning country is the type that pretty much is always a net loss from an economical standpoint. there's far more poor people in need of health care then there's rich people in need of it and obviously poor people can't pay as much or at all for the health care yet they're a part of society that's in most need of health care and the part you want to keep healthy for the sake of peaceful existence in your country.

[Simon_Jester]

The kind of situation where privatizing health care COULD conceivably be good for a country would be... oh, something like this. Note that this is a parody version, I am not even saying this is realistic AT ALL. Just that it's the kind of situation in which health care privatization would start to make sense.

...

Suppose that in the nation of Triagistan there are enough people who are sick enough, with enough severe diseases, that in theory 100% of GDP could be 'usefully' spent just on keeping all those sick people alive and well. Suppose that the government cares so intensely about caring for sick people that it tends to ignore or minimize any economic statistics saying "yo, we spend too much effort on sick people." Accordingly, the government extracts very large shares of all forms of economic goods and services, to maximize the resources available for health care.

The people cannot vote for lower taxes, either because of a universal public consensus that super-high tax rates to care for the sick are OK, or because (more likely) the government is actually a tyranny or an oligarchy run by a managerial class.

Very little else gets done. Little new infrastructure gets built, except insofar as it directly benefits the health industry. Education shrivels, except insofar as it helps train new doctors and nurses and other members of the health industry. Art and science atrophy, except insofar as they contribute to advances in medicine. Compared to other developed countries, Triagistan leads the world in health care assets per capita, but lags in many other areas. Eventually, neglect of other sectors of the economy leads to stagnation, then to increasing permanent structural problems, then to collapse of the economy.

...

This is basically an exaggerated version of happened to the Soviets, only with ICBMs instead of MRI machines and bullets instead of bandaids.

In that situation, privatization saves you because it forces you to acknowledge that yes, it is a bad idea to spend 60% of GDP on health care instead of, say, 20%.

But real democratic governments aren't likely to ever have Triagistan's exact problem in any event, whether their health care systems are public or private. So it's a moot point.

[aerius]

The first thing to understand is that non-profit does not equal low cost. For example, if I were corporation that was making a massive profit from price gouging my customers I could spend the entire profit on corporate jets, hookers, and blow, get some lawyers & accountants to legitimize it as a business & operating expense and presto, I'm a non-profit.

If the goal is affordable healthcare, the first step is tearing up all the antitrust exemptions such as McCarran-Ferguson that the healthcare industry has written for itself over the years. Those exemptions allow the industry to effectively function as a monopoly/cartel and collude to price gouge the fuck out of everyone.

Next we enforce Robinson-Patman and other consumer protection laws to shut down price discrimination. This makes it illegal for hospitals to bill patients at wildly different rates depending on which whether they're insured and which insurance provider they're under. It also shuts down price gouging so they can't bill you $200 for an Advil or a bandaid that you can buy at a drugstore for pennies.

Do the above and healthcare costs will plummet to the point where most people can afford them even without insurance. Let's take childbirth for example, last time I checked the average cost in the US was around $9000, up here in Canada it's around $1400 CAD, or a bit over $1100 US at current exchange rates. And we have lower infant mortality. Take all the hospital bills in the US and discount them by 80-90%, once you do that insurance will be affordable for almost everyone.

[cadbrowser]

Please excuse the formating. I didn't see a multi-quote function and did the best I could. So there will be some emphasis possibly by the original author that may have been left out...unintentionally.

Ultimately the problem isn't getting health cover for a part of the population which is generally healthy, everybody wants to insure them. It's getting insurance for people who are actually likely to claim more than they pay in which is the tricky bit. Insurance is really all about the healthy subsidising the sick on the grounds that they might be sick one day.

Right, I get that. Using the masses of healthy that can pay to subsidize taking care of those that are ill and poorer. It's a fairly low-risk gamble, really. Even more so when having Health Care is mandatory by the Federal Government.

---

Here is a link to some information you might find useful. The first company that is part of BCBS was founded in 1929. That was 13 years before penicillin become available to civilians. Costs were less because there was so much less that could be done. There were opiate painkillers, aspirin, a few specific treatments like quinine for malaria and insulin for diabetes, and surgery - but less sophisticated surgery than we perform today. No kidney dialysis. No organ transplants. No cancer chemotherapy. No open heart surgery. No limb re-attachment.

It's not just price gouging - we can do more, but all of those things have a cost. Some cost little, like antibiotics (usually). Some cost a lot. Some cost a lot for years.

I can tell you that it was 1994 when some of the BCBS companies went from non-profit to for-profit. It was not without controversy.

Thank you for the link Broomstick, I'll read that pdf later on today as it does interest me. I get where you are coming from with regards to the proceedures and medicines in that they are far more superior than they every have been in medical history. With that advancement comes cost...a lot of cost.

With your "Some cost for a lot of years.", are you referring to the patent rights for drugs/antibiotics/etc before they can become available for generic manufactuer?

Doesn't matter - that's far too low an income for a health insurance company.

? - I don't understand your reply, can you elaborate a bit for me please?

There is no hospital visit that costs only $200/occurance. That's for doctor's office visits. Hospital visits are at least an order of magnitude greater, often two, and can be considerably more than that.

Ah yes...my apologies, I did mean doctor's office visit.

According to THIS: Average cost of a 3-day hospital stay is around 30k; 10x more for comprehensive cancer care and other items that you mentioned.

Ok...lesson learned. I have A LOT more research to do and numbers to calculate. Frustrating...

---

Why do you want a privately run solution ?

I don't think I am really asking for a privatzed solution, per se. I think the title is misleading, my bad. But since, here in the US, the idea of a National one is pretty much off the table. I just want a truly affordable working solution based on the following:

*The richest nation in the world can't pull it's head out of its ass long enough to take care of it's own people. I suspect that this is due to the prevelence of the religious right and how they look down on someone...anyone that needs "assistance".

*From the above - this also means that "National Heathcare" is off and always will be off because that'd make us...

DUN DUN DUUUUUNNNNN

...Socialist! And us "good christian boys and girls" must remain capitalist...right?

*It is my personal opinion that profiting from suffering (the way hospital's and pharma do) is immoral and unethical.

*In my minds eye, to me it would be like how Wal-Mart came in and with sheer buying power was able to basically pay whatever price they wanted, and knock out the competition by starving them. Why couldn't something like that be done by offering affordable heath coverage?

---

Simon_Jester

You bring up some great points with your analogy regarding the USSR & Military costs. I didn't want to quote as I didn't really have any rebuttals to what you said, but I did want to acknowledge it.

---

The first thing to understand is that non-profit does not equal low cost. For example, if I were corporation that was making a massive profit from price gouging my customers I could spend the entire profit on corporate jets, hookers, and blow, get some lawyers & accountants to legitimize it as a business & operating expense and presto, I'm a non-profit.

Oh, I totally understand that. My point of it being a legitimate non-profit organization is due to my personal elthical convictions noted above. I would imagine that the Canadian Government doesn't consider their National Healthcare Coverage a "for profit" venture...right? So my line of thinking is parallel.

If the goal is affordable healthcare, the first step is tearing up all the antitrust exemptions such as McCarran-Ferguson that the healthcare industry has written for itself over the years. Those exemptions allow the industry to effectively function as a monopoly/cartel and collude to price gouge the fuck out of everyone.

Next we enforce Robinson-Patman and other consumer protection laws to shut down price discrimination. This makes it illegal for hospitals to bill patients at wildly different rates depending on which whether they're insured and which insurance provider they're under. It also shuts down price gouging so they can't bill you $200 for an Advil or a bandaid that you can buy at a drugstore for pennies.

Do the above and healthcare costs will plummet to the point where most people can afford them even without insurance. Let's take childbirth for example, last time I checked the average cost in the US was around $9000, up here in Canada it's around $1400 CAD, or a bit over $1100 US at current exchange rates. And we have lower infant mortality. Take all the hospital bills in the US and discount them by 80-90%, once you do that insurance will be affordable for almost everyone.

Yes...this is exactly the ideas that have been obsessing my mind. I just have no idea where to start or if, in my lifetime, it would be possible.

Consider what would happen to the profits of those that do offer Heathcare if the above was done? Obviously they are all making money - and profit. Otherwise they wouldn't be still around. Profit is nothing more than what is left over after cost. Imagine the same companies rolling that profit over to keep breaking down the bullshit gouging/exemptions and etc.

It can be done.

[Broomstick]

Doesn't matter - that's far too low an income for a health insurance company.

? - I don't understand your reply, can you elaborate a bit for me please?

Health insurance companies need to have a HUGE reserve of resources/cash in order to pay for catastrophic care. I've worked for a couple companies that self-insured, meaning company of, say, a few hundred to a few thousand employees do indeed set up a scheme such as you propose. Those self-insurance plans invariably have two features:
- they hire a company to administrate the plan, invariably a larger health insurance company with the expertise to do this (Blue Cross Blue Shield companies often have subsidiaries or internal work groups to do this), and
- they have re-insurance. That is, the insurance plan purchases "catastrophic" insurance to cover instances where their own reserves are inadequate.

Let's discuss what might be meant by "catastrophic", shall we?

For our example I will be using the The Station nightclub fire in Rhode Island. When this is mentioned a figure of 100 dead is usual mentioned. What isn't mentioned is the 230 injured, mostly with burns. There are a lot of places to get treatment cost extimates and averages and there is some variation. Let use this one for now. If all 230 of those people had "moderate burns" at an average cost of treatment of around $200k/patient then treatment for all of those people would be around $46,000,000. In actual fact, quite a few of them had severe burns, which are around 1.6 million apiece to treat without complications, like, say, broken bones acquired during a crowd-crush rush for the exit of a burning building, treating lung damage from breathing toxic gasses, and so forth. Treatment for severe, complicated burn injuries can reach $10 million. 10 such patients (they don't all have to be from the same incident) will cost $100 million. 100 such patients will cost $1 billion... and you still have all the other people insured who also need care.

The CDC reports that typical burn treatment costs in the US reach about $7.5 billion per year. That's just for burns.

Now add in cancer treatment, heart disease, severe trauma, genetic disorders like cystic fibrosis.... For a small company, such as you're proposing, even one patient with a particular type of disorder can result in insolvency.

According to THIS: Average cost of a 3-day hospital stay is around 30k; 10x more for comprehensive cancer care and other items that you mentioned.

Ok...lesson learned. I have A LOT more research to do and numbers to calculate. Frustrating...

Yep. It is an extremely complicated problem.

Why do you want a privately run solution ?

I don't think I am really asking for a privatzed solution, per se. I think the title is misleading, my bad. But since, here in the US, the idea of a National one is pretty much off the table. I just want a truly affordable working solution based on the following:

*The richest nation in the world can't pull it's head out of its ass long enough to take care of it's own people. I suspect that this is due to the prevelence of the religious right and how they look down on someone...anyone that needs "assistance".

*From the above - this also means that "National Heathcare" is off and always will be off because that'd make us...

DUN DUN DUUUUUNNNNN

...Socialist! And us "good christian boys and girls" must remain capitalist...right?

What is not off the table is state-level insurance companies. I used to work for Blue Cross and Blue Shield in the 1990's through the early 2000's and remember this being discussed. Keep in mind, this is one of the more solid health insurance companies in the US with a LOT of experience and expertise. The conclusion was that while this was viable for a state like California, which is larger than some nations, it is NOT viable for a state like Wyoming with a population between 500,000 and 600,000 people because there are simple not enough people to create a large enough risk pool to cover catastrophes. A small population state could not self-insure long term because inevitably Something Would Happen. The only way something like that could work would be to allow low-population states to pool their resources.

I wish I could give more background and explanation but these conclusions were arrived at by actuaries and experts in statistical analysis and I just don't have that level of skill in the needed areas.

Of course, that would make us like Canada (which demonstrates that model can work, by the way) which is an anathema to some on the far right. Of course, some on the far right are goddamned fucking Nazis (as recently demonstrated in Charlottesville) and that sort is perfectly happy letting the sick and "defective" die, when they aren't actively helping them to that end.

[Broomstick]

With your "Some cost for a lot of years.", are you referring to the patent rights for drugs/antibiotics/etc before they can become available for generic manufactuer?

Another complicated question.

Let's look at a few examples.

How about Type 1 diabetes, which is a disease we've had treatment for which we've had treatment a long time. Average cost per year is around $13,000 and about 2/3 of that is directly related to diabetes. Wait, what? See that - only two thirds is directly related to diabetes. This is one reason I say "complicated". Because, in addition to needing the same routine stuff everyone else does it's a damn rare diabetic who doesn't have other problems, which may or may not be indirectly related to their diabetes. Well, OK, expensive on one level, but probably affordable for your proposed size of company. It won't break the bank.

Of course, there are various considerations - more frequent glucose testing typically gives better outcomes, but restricting testing supplies is one way to cut costs. Humulin - insulin produced by bacteria spliced with human genes to produce the hormone chemically identical to that made by the human body - costs more than the old fashioned insulin from sheep and various other livestock (or at least it used to - not so sure these days what with ramping up production) but being essentially human insulin it works better in the human body, doesn't result in allergies (and if a diabetic becomes allergic to, say, sheep insulin and that's the only sort available.... well, game over), and so on... well, is it "price gouging" to use the more expensive stuff or not? How much greater cost is justifiable?

OK, here's another - I have a friend who has a daughter with cystic fibrosis. She was recently approved for a new drug to treat this condition, which costs $259,000 per year. OF COURSE insurance is covering it, almost no one has the money to pay that out of pocket. Her alternative is a lung transplant. Assuming you find a donor (which is in no way guaranteed) that costs 500,000-700,000. For just the transplant. Post-transplant, cost is about $70,000 per year (this actually varies a lot for a bunch of reasons, so I pick something in the middle of costs I saw listed). So the new drug is "cheaper" than a transplant for probably the first 3-4 years. All this, by the way, over the typical annual costs of between $13k and $50k to treat this disease. See how it adds up?

The question is... is the pharma company price-gouging on that drug or not? How do you determine that? Oh, by the way - this isn't even the top end of pricey drugs, which can reach $500,000 per year per patient.

(Personally, I think there is some price-gouging with the new CF drugs but I have no way to prove it. The company admits they're using the retail price tag to help subsidize reduced cost access to some patients so if everyone was charged a uniform price yes, it probably would be lower - but is subsidizing the poor "gouging" or not?)

By the way - there are about 30,000 people in the US with cystic fibrosis. You get to do the math on that one.

Here's another: Gleevec. This drug can convert certain leukemias into a chronic rather than terminal disease. Wholesale cost for an annual supply of the drug in the US at one point reached $120k per year. In the UK it was around 20K-30K. For the same damn drug. For the same dosage and period of treatment. Yeah, price gouging. That one wound up in court. It's still in court.

Here's another: It costs about 70k per year for dialysis for someone with end stage kidney disease. That's in addition to any other medical problems they have. While most people only survive on dialysis for 5-10 years (that's 350k to 700k per such patient) some have lived 20 years (1.4 million) or even 30 years (2.1 million) on dialysis. Keep in mind, diabetes is one such cause of kidney failure. So... that's 70K + 15k per year for a diabetic on dialysis or around $85k per year. Year after year.

And there's nothing preventing such a person from, say, suffering a catastrophic burn, or having cancer (initial treatment about 70k and up, that would be the first few months, maybe two rounds of chemo, that sort of thing. Can greatly exceed that) or heart disease. Or you could have a cystic fibrosis patient with diabetes who is burned in a house fire...

Yes, some of this is getting into rare territory, but you have 300 million people in the US. Rare shit happens. Surprisingly often, in fact.

We didn't have to worry about those costs in 1929 when the first company that became BCBS was founded. Do you know why? Because none of those people lived very long. People with cystic fibrosis died before adolescence. People with severe burns died in days or weeks. People with leukemia died in about a year. People without functional kidneys died in days to maybe a week.

That's why I said a big reason health care costs more is because we can do more, and keep doing more. Used to be kids with CF died by around age 6. Now they average 37 years. That's 30 years more of medical costs, and at today's prices, assuming you aren't on the super expensive drugs (which, eventually, they all would wind up on due to on-going damage) that's around $300k to about a million. Except the last 5 years or so, you'll have the super expensive drugs so add on another 2-3 million. Yep. Around 4 million each. Times 30,000 people with CF. That's about $120 billion (if I did the math right) for the lifetime costs of all the CF patients currently alive in the US. Used to be a hell of a lot cheaper because all those folks used to just die after 5-10 years.

That's just ONE severe disease. Just one. Know how many other severe, costly diseases there are? Sickle-cell anemia, for example. Diabetes. Heart disease. Cancer

Even if you could eliminate half the cost by getting rid of price-gouging the costs would still be enormous.

Some of this cost is NOT price gouging. Going back to burn patients, if you're going to survive a horrific burn you will need round the clock nursing care for some time. Nurses have to be paid. Doctors have to be paid and even if you argue they're price gouging with their fees you still need to pay them something. The pharmacists filling the prescriptions for all the required medications and supplies need to be paid. There is a base cost to producing all the needed supplies AND the cost of a factory with highly controlled, sterile production methods and fabrication lines.

There is a floor below which you can't reduce costs without letting people simply die. There is debate as to where that floor is, but it does exist.

Even more confusing - there are subsidies for some of the lesser cost items. It's becoming quite common in the US for certain retail pharmacies to give away certain common antibiotics and medications. This can become quite confusing because those medicines aren't really free, there is a cost to manufacturing, packaging, transporting, and dispensing them. Pointing to them and saying "well, THAT one is free, why aren't all the others?" is the opposite distortion from price gouging.

[cadbrowser]

Going back to burn patients, if you're going to survive a horrific burn...

I know about burns and being a burn victim. When I was 11 or 12, I was caught in the attic of a house fire (my room was up there). I suffered 2nd & 3rd degree burns on 20% of my body. In addition my lungs suffered the most damage. The hospital bill wasn't cheap. The church I was in at the time told my dad God punished me for something he didn't/did do, and that it would be worse if I was kept in the hospital (Something about lack of faith and taking the *lord's name in vain). After 5 days, I was taken out of the hospital and we lived with another family with a wood burning stove. Yeah...that smell, those nightmares.

Also, my wife has Rheumatoid Arthritis and is taking Orencia (via self administered shots) once a week. IIRC, without insurance and a special plan that they offer, we'd have to pay like $6k per month.

I will respond to the rest of everything shortly. Also, I sincerely appreciate you filling me in on a lot of the stuff I am just plain ignorant on.

I think a key thing to ask though is where does the cost come from for some of these treatments and surgeries?

Why does it cost 500,000 to transplant a lung? I know the doctor doesn't get hardly any of that (unless that's changed).

What does it cost in Canada to have a lung transplant?

Why, in the US, does an IV bag of Saline Solution cost so fucking much?

Dr. Frost, the anesthesiologist, spent three days in the same hospital and owed only $8, thanks to insurance coverage by United HealthCare. Still, she was baffled by the charges: $6,844, including $546 for six liters of saline that cost the hospital $5.16.

Give me some time to re-read everything else and if I see anything that needs further explaining or if I have any rebuttals, I'll post more.

*It was the belief of the church that casting doubt, either verbally or through action (going to the hospital), on anything that god said he'd do (heal the sick), then that was taking the lord's name in vain.

[Broomstick]

Why does it cost 500,000 to transplant a lung? I know the doctor doesn't get hardly any of that (unless that's changed).

Well, aside from the highly specialized nursing care/surgery involved....?

Consider transportation for the donor lung. Typically, you have to send a transplant crew to the donor (because, being dead, they won't be going anywhere on their own), remove the organs carefully, under proper conditions (so far like normal surgery), then transport the damn thing quickly. Which means not only do you take it by ambulance to an airport you then have to use a private plane - typically a fast one. And that can cost hundreds of dollars per hour. That's not price gouging, that's fuel, insurance, maintenance, and pilots that probably make about $30k a year so no one is getting rich. Sending a group to get an organ and transport it quickly could easily be $5k or more of the cost right there, maybe $10k. (That's one reason why live kidney donations can be less expensive than, say, a heart or lung or liver - you can transport the donor to the recipient's location on less expensive, slower transport). That's not something people think about when asking "why does this cost so much?". Anything as complex as an organ transplant is going to have a bunch of costs like that, which won't occur to someone unfamiliar with the entire process.

There's also the testing and tissue typing, the maintenance of information databases on who needs a donor, personnel at medical centers who are trained to ask grieving relatives for body parts, and other sorts of infrastructure that need to be maintained 24/7/365 in order to make this whole system work. If you don't have this infrastructure the system doesn't work and it all has to be paid for.

What does it cost in Canada to have a lung transplant?

From what I've found on line with a brief search, it's slightly less, with things like procurement and transportation costs being pretty much the same. The main difference seems to be the surgeons get a bit more money in the US. I don't think there is price-gouging going on with the transplants, I think they're just a really complex thing that will cost a lot of money no matter what, because that's the base cost of the technology.

Now, if we had a source of new lungs that didn't require people to get so sick prior to transplant and didn't require anti-rejection drugs afterward that would probably bring the cost down considerably but that would require some sort of breakthrough (probably more than one) like being able to grow organs to order.

Something like a kidney transplant between identical twins, for example, is significantly cheaper than between two people who aren't genetically identical because 1) you don't have to put the recipient on a waiting list, 2) you don't have to wait with them getting sicker and sicker, and 3) no anti-rejection drugs are required afterward, which makes a big difference both short and long term. But most people don't have identical twins and even then taking your twin's heart, lung, or liver is not feasible in any sort of ethical situation.

Why, in the US, does an IV bag of Saline Solution cost so fucking much?

Due to high costs a lot of people can't pay, but the hospital renders treatment anyway, and in the case of life-saving emergency treatment they are obligated by law to treat even if they know in advance they won't get a penny in payment. But somehow the supplies used must be paid for and salaries paid and the utility bills for the lights...

How did you THINK this was being paid for? Pixie dust?

A bag of saline that costs $1 to make costs $500 because THAT is how the cost of uncompensated care is covered.

You can dick around with other explanations but that's what it really comes down to. In order to cover the base cost of treatment the hospital has to right off as bad debt cost for everything else is increased. When someone says "the insured and those with money wind up paying for the uninsured and the destitute" that is what they are talking about. The fact that it is jacked up that much indicates just how bad a problem it is.

If you got rid of the inefficiencies and the price gouging saline in the US would have a cost more like in other parts of the world. It still won't cost a dollar - you still have to a pay for the nursing care needed and the room overhead at the very least - but it won't cost 500, either.

[Simon_Jester]

In short, the US is unique among developed countries in NOT having taxpayer-funded health care that consistently answers the question "who's going to pay for all this?"

The US is also unique in spending like 50% more per capita than almost any other developed country and twice as much as a lot of them.

This is not just some kind of mutant coincidence.

[cadbrowser]

I...honestly don't know what to say. Broomstick, you have opened my eyes to a lot here. Thank you once again.

In that article I linked with the Saline Bag, why are Hospital admins so tight-lipped about costs then? It doesn't make sense. You have ignorant people like me thinking that a huge majority of the overpriced medical stuff is mostly price gouging, when there are some things that could easily be explained by Hospitals that actually make sense.

"X" News reporter wants to uncover the price gouging for IV bags and demands to know what the costs are while spinning wild conspiracy theories about middlemen controlling it all backstage.

Why don't that admin just look at them and say something like: "This year alone, we used "X-THOUSANDS" IV bags for those that don't have insurance and for those that can't/won't pay. WE still have to buy them, they aren't free. The industry allows us to offset the losses by up charging those that have insurance. THAT'S WHY, so we can continue to provide for those that need it and can't pay."

[Broomstick]

The short answer: it's complicated.

There IS some mark up with the middlemen - who, after all, need to make a living, too. My father, who was a pharmacist from the 1950's through the 1990's (a huge swath of modern medical history) remembers when making IV saline in the hospital basement was a routine thing. By centralizing to factories with very strict controls quality and sterility were improved and made very consistent, so that's a good thing, but then you need to distribute from the central factory which means middle-men and drivers and various other people so a lot of the savings gets eaten up by those costs and the price doesn't differ that much in the end. But making a living isn't "price-gouging", although I'm certain there is some amount of that going on.

As for hospitals being honest - if they were, there would be push-back from people saying "but I'M paying MY bill - why should I have to foot the bill for those deadbeats?" Think of all the people claiming that taxes are a form of theft - what do you think they'd make of that? Yet our society has mandated that hospitals, essentially, provide certain types of care for free. Although, of course, it's not free to the hospital. I think a lot of people assume charities and donations make up the difference but they don't. Americans are generous, but their generosity isn't sufficient to cover the costs here. Hospitals make it up by inflating enough prices on smaller items to make up the difference.

Some of the mark up is due to insurance companies trying to negotiate better prices. The insurance companies say we'll guarantee you X number of patients and you will get paid Y for them, at some discount from "retail". Except the insurance companies - who are the ones who actually control access - will try to negotiate for cost or less than cost. So, to compensate, hospitals will raise the "retail" rates knowing most people won't actually be paying that price. Which is an insane way to do business because then NOBODY knows what actual costs are. That's why saying "well, we should make people more aware of costs so they'll be efficient consumers" doesn't work. Aside from being unable to negotiate or make choices if, say, you're unconscious on a gurney, nobody knows what actual prices are for anything.

This is also why, if you have no insurance, you can walk into a place like that and say "I'll pay cash up front if you'll drop the price by 40%" and get results. I've quickly negotiated to half stated retail price as a single, impoverished person offering cold, hard cash for treatment. Why? Because the retail cost is inflated and they'll happily take half that (which still gives them margin above cost to pay their bills) right now instead of trying to chase you down for bad debt. The catch is that if you have ANY form of insurance at all, any, then you MUST pay full retail. This leads to situations where having an insurance plan with a very high deductible can actually hurt you because you lose a lot of your ability to negotiate as a cash customer due to how policies are constructed and constrained by contracts with the large insurance companies.

TL:DR - it's complicates. And stupid. And NOT a free market.

[Simon_Jester]

Right.

Strictly, a free market would result in more accurate cost accounting if you eliminated all the pricing cartels. Profit versus nonprofit might or might not change much, but a free market would have that effect.

The problem is, a free market would ALSO say "Sorry, we totally have the technology to cure your relatively easily treatable life-threatening medical problem, and we have the skills and the equipment right here, but we're not gonna do it because we're not convinced you can pay the market price for the care you need. So go crawl in a hole and die kthxbai."

It would be effective at achieving a specific goal (cheap health care) but would largely defeat the main purpose of the art of medicine (namely, taking those who are crippled or deathly ill and restoring their health and life).

The vast majority of humans who have ever lived died of medical conditions we would consider treatable, or complications of medical conditions we could ameliorate using First World technology and knowledge. From a certain point of view, "died too soon, for lack of proper health care" is the natural state of humanity, and the entire reason we even have a medical industry is to lift ourselves out of that (nasty, brutish, short) life in a state nature.

But if we really left it up to the market which people "die too soon, for lack of proper health care," the answer would be "not all, but a lot." Most people are not happy with this outcome on a fundamental level, even those who are nominally in favor of the free market. I know I'm not.

[whackadoodle]

Ok. So let's speculate that we can reform the US healthcare system well enough that it corrects back to its historical norm of 5% of GDP. What's going to happen to the economy when The GDP drops by 14% virtually overnight?

All of that growth in "healthcare" jobs in the last decade? Not folks wearing scrubs or lab coats. Mostly folks working in positions that exist solely to manage the waste, and for outright predatory businesses like pharmacy benefits managers. Most of these people will lose their jobs. That's a lot of angry voters.

Combine those voters with the people who get hurt from the massive market correction - If you were a member of Congress, how would you feel about the prospect of REAL healthcare reform?

[Broomstick]

Ok. So let's speculate that we can reform the US healthcare system well enough that it corrects back to its historical norm of 5% of GDP.

Not going to happen. Modern health care is going to be at least 10-15%. It's back to that "we can do more" thing, which is a good thing from the perspective of relieving suffering and saving lives.

What's going to happen to the economy when The GDP drops by 14% virtually overnight?

All of that growth in "healthcare" jobs in the last decade? Not folks wearing scrubs or lab coats. Mostly folks working in positions that exist solely to manage the waste, and for outright predatory businesses like pharmacy benefits managers. Most of these people will lose their jobs. That's a lot of angry voters.

They'll do what I did when I got laid off from the Evil Insurance Empire: find new jobs. It may take awhile (four years for me, but then, it was the Great Recession). Sorry it's going to cause pain for them, and believe me, I do understand and empathize, but long term the vast majority will be better off.

[whackadoodle]

Ok. So let's speculate that we can reform the US healthcare system well enough that it corrects back to its historical norm of 5% of GDP.

Not going to happen. Modern health care is going to be at least 10-15%. It's back to that "we can do more" thing, which is a good thing from the perspective of relieving suffering and saving lives.

Karl Denninger has a one-sentence bill that would collapse a lot of the cost of healthcare in this country:

Here it is:

"Notwithstanding any other provision in state or federal law, a person who presents themselves while uninsured to any provider of a medical good or service shall not be charged a price greater than that which Medicare pays for the same drug, device, service or combination thereof."

That's it.

One sentence.

If you want to add a penalty clause with it I propose the following:

"Any bill rendered to a person in excess of said amounts shall (1) be deemed void, with all services and goods provided as a gift without charge or taxable consequence to said consumer but not deductible by said physician or facility from any income or occupational tax and (2) is immediately due to the customer in the exact amount presented as liquidated damages for the fraud so-attempted."

It ends the "Chargemaster" ripoff game.

It ends the $150,000 snake bite or the $80,000 scorpion sting.

It ends the $500,000 cancer treatment.

It ends all of that, immediately and instantly.

I remind you that Medicare is required to set pay rates by law at a level that in fact are profitable -- that is, above cost by a modest amount -- for everything it covers. Further, those pay rates are audited regularly to prove that they in fact are above cost.

He's written an entire healthcare bill that, although there are a number of nits to pick (such as mandatory dietary changes for Type II diabetics), still has many proposals that would end a lot of the waste and abuse in the industry.

What's going to happen to the economy when The GDP drops by 14% virtually overnight?

All of that growth in "healthcare" jobs in the last decade? Not folks wearing scrubs or lab coats. Mostly folks working in positions that exist solely to manage the waste, and for outright predatory businesses like pharmacy benefits managers. Most of these people will lose their jobs. That's a lot of angry voters.

They'll do what I did when I got laid off from the Evil Insurance Empire: find new jobs. It may take awhile (four years for me, but then, it was the Great Recession). Sorry it's going to cause pain for them, and believe me, I do understand and empathize, but long term the vast majority will be better off.

Of course they will get new employment. Of course reducing spend in healthcare and redirecting that money into wages and more productive sectors of the economy will be a good thing. Not my point. My point is that House-critters face elections bi-annually as do 1/3rd of Senators. Voters, being rational as always (see the 2016 results), will take out their pain on their representatives. They sure as hell did in 2010 over the ACA, and that election decapitated an up-and-coming class of Democrats. And, how did repeal and replace go?

[Broomstick]

I dispute that Medicare actually pays a sustainable rate to medical providers, but that could be another entire thread. Medicaid is even worse. I think the fees charged by both of those need to be raise a bit, and it would be sustainable for Medicare/aid to pay if the price inflation elsewhere, the waste, and the bulk of required uncompensated care was reduced.

[Simon_Jester]

Ok. So let's speculate that we can reform the US healthcare system well enough that it corrects back to its historical norm of 5% of GDP. What's going to happen to the economy when The GDP drops by 14% virtually overnight?

It won't drop back to historical norms, it'll drop back to the levels every other developed country experiences. Typical per capita health expenditure in those countries is about two thirds to one half of what the US's is, so we can reasonably expect the health industry's share of GDP to drop from 20% to about 10-13%.

This is still a problem but not as overpowering a problem as you make it out to be.

Furthermore, all that money still gets spent, it just doesn't get spent on hospitals. Other sectors of the economy would grow significantly, because suddenly sick people and old people have more money to spare on other purposes, and sick poor people have better access to health care and are thus able to accomplish more. We'd see more growth of universities, more demand for consumer goods, more demand for services, and so on.

Shrinking a specific industry as a share of GDP is not, in itself, a disaster. Furthermore, any such shrinking process would take place over a period of several years, which would make it much easier to adjust.

All of that growth in "healthcare" jobs in the last decade? Not folks wearing scrubs or lab coats. Mostly folks working in positions that exist solely to manage the waste, and for outright predatory businesses like pharmacy benefits managers. Most of these people will lose their jobs. That's a lot of angry voters.

Combine those voters with the people who get hurt from the massive market correction - If you were a member of Congress, how would you feel about the prospect of REAL healthcare reform?

I'd feel good, but some of my coworkers would feel bad... which is why I would be voting for single-payer health insurance, and also why some of them would be voting against.

I dispute that Medicare actually pays a sustainable rate to medical providers, but that could be another entire thread. Medicaid is even worse. I think the fees charged by both of those need to be raise a bit, and it would be sustainable for Medicare/aid to pay if the price inflation elsewhere, the waste, and the bulk of required uncompensated care was reduced.

Yeah.

Realistically, if we establish "Medicare for all" or "the uninsured pay Medicare prices," what's going to happen is that a huge line of doctors and hospital administrators will form in Washington, D.C. They will angrily wave binders full of very scary documentation from their accountants proving that if they charge the existing Medicare price to all customers, they'll go out of business and nobody gets any health care.

And they'll win that debate.

Thus, there will be haggling! Medicare will be forced to accept higher prices for services. Probably fairly close to the real market price of what it costs to provide those services, instead of the rates they pay now, which are indirectly subsidized by the prices paid by both some other insurance companies and the uninsured.

Instead of spending around 5% of GDP on health care (the number Whackadoodle implies), we'll end up paying about 10-15%, because that's what everyone else pays, and everyone else has essentially the same system. Namely, the federal government of whatever country agrees to pay a certain price for medical care, calculated at a level that permits the health care industry to stay in business without allowing for massive inflationary price bloat... And pays it.

The US is not so different from other First World nations what we should have radically more expensive OR radically cheaper health care if we ran our system the same way.