Health Care, Aug 20, Time Goes By Challange

Today I spent some time trying to understand why so many people say we in the United States have the best health care in the world.  I looked up some statistics.  First, I checked the adult mortality rate:  your chances of dying between the ages of 15 and 60.  About 25 countries, including Cuba, have us beat on that one.  Then I looked at infant mortality rate.  Same general result.  We are way down the list.  Then deaths from heart disease and cancer.  We are below all the European countries and Canada. 

All the countries that do better than the United States on adult mortality, infant mortality, cance and heart disease have government health care plans. 

Health care reforn without a government option is worse than the status quo.  At least with the present system we have Medicare, a single payer government plan.  That covers those of us over 65.  Without a government option for the rest of our population they will inevitably raid Medicare and Medicaid.

The substitution of the so-called health care cooperative for the government option is simply a slight of hand for the creation of more insurance companies.

I include here part of a post I wrote a few weeks ago about the health care debate that includes an example of how these cooperatives work. It recounts my husband’s experience with Group Health of Puget Sound, a so-called cooperative that has been promoted as an example of how the cooperatives work.

My husband, Jerry, insured his late wife, Susy, with Group Health.  He himself had Medicare, but she was too young.

Group Health is being held up as an example of a model for a “cooperative” health care plan that would be a “compromise” solution to the Republicans’ objection to a government health plan.  There is an article in the New York Times discussing Group Health.  Toward the end of the article it states that “Technically, Group Health was misnamed. . . . . Structured as a not-for-profit corporation, its revenues (2.6 billion last year) are reinvested rather than redistributed among members.  But it is governed like a cooperative – and calls itself one – because its board consists of and is elected by members.”  In fact, according to the article, only seven-tenths of 1 percent of enrollees voted in the last board election.

In fact, Group Health is an insurance company.  Apparently its fees are slightly lower than other insurance companies, supposedly because its records are computerized and its doctors are paid a salary (not fee for service).  Salaries are based on “performance.”  The article does not say who evaluates performance, or what criteria are used in the evaluation.  But I’d be willing to bet my bottom dollar that keeping cost down is a biggie!

At Group Health, according to the Times article, patients are assigned a team of primary care practitioners who are responsible for their health.  Notice that they are assigned practitioners.  What that means is that you don’t choose your own doctor, and you don’t even choose whether or not you see a doctor.  You may see a nurse, and you don’t have a say in which it is. 

Suppose you were a doctor working for Group Health and your salary was based on your performance.  Your performance would be measured by the administrators running the insurance company (Group Health).  These administrators would be very interested in keeping costs down, and probably secondarily, in keeping patients healthy (or perhaps in keeping healthy patients).  You would be disinclined to order tests for patients, especially expensive tests.  You would prefer not to treat the really sick ones.  They would need expensive care and would spoil your record of keeping costs down.

The times article states further: “Medical practices, and insurance coverage decisions, are driven by the company’s own research into which drugs and procedures are most effective.” 

Don’t let them fool you.  It’s an insurance company, pure and simple.

Here’s what happened to Jerry’s wife.  Some years after he took out the insurance she discovered that she had metastasized breast cancer, the same thing Elizabeth Edwards has.  It would eventually kill her, but there were treatments which could significantly prolong her life.  She was given chemotherapy and the cancer went into remission.  The tumors were not gone, but they were no longer growing.  After another year they came back.  Jerry got a letter from Group Health saying they would no longer cover Susy’s cancer.  He read the policy, which had been sold to him by an insurance broker (because Group Health is an insurance company) and it had a lot of language in it that was difficult to understand, but which did seem to indicate that the insurance company could terminate coverage under various conditions.

Is anyone surprised by this story?  Isn’t this standard insurance company practice?  Don’t get really sick because the doctors will get paid less and the insurance company will get less money.

Jerry made a fuss.  The original broker got involved.  (“This is outrageous!” is what he said to Jerry.)  Eventually he got coverage reinstated, and Susy lived another 5 years. 

Jerry and I both have Medicare.  He wouldn’t be paid to have Group Health.  Medicare isn’t perfect, but it is the best health insurance I ever had.  We supplement it with a medigap policy.  That is not cheap, but it allows us to choose our own doctor and to decide when to go.  We can see a specialist when we need to, and the insurance company has nothing to do with the decision.  We decide, with the recommendation of our doctor, which specialists to see.
President Obama said that if we like the insurance we have we can keep it.  I sure hope he keeps that promise, because I really don’t want to be forced into something like Group Health.

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13 Responses to Health Care, Aug 20, Time Goes By Challange

  1. lilalia says:

    It really is all just a matter of having a choice, receiving proper services at an affordable price fo all.. something that most private insurace companies are not really interested in providing, are they? Thanks for writing the post, it was very interesting. I had never heard of Group Health.

  2. Thank you for sharing this experience. I did not understand about the co-ops but you make it quite clear: they’re insurance companies in disguise. We really need the public government option to be part of this health care reform bill!

  3. Cile says:

    Thank you for this informative post! It reminded me of the poor health care I received in the 80′s with an HMO. I then realized with a shock as I sit here that had I been raised to integrate health care as being a part of my normal dialog growing up – as opposed to “that which we may or may not be able to afford” – how different my entire approach to my own self care would have been for my entire life! Who knew?

  4. Hattie says:

    My daughter and son in law have Group Health. I was not aware that they have the status of a non-profit and yet make a profit. That is certainly interesting. I wonder if Kaiser is the same. My husband and I have Kaiser. Worth doing a little research.

  5. Hattie says:

    Well, that took me thirty seconds thanks to Google. Yes, they make big profits by stiffing the patients. How they can get away with non-profit status is beyond me. Thanks for drawing my attention to this.

  6. Betty Hurst says:

    Thanks for sharing. You know, if we take the money the insurance companies use for paying staff to find reasons to deny coverage, marketing, real estate and their 35% profits (obscene when the $’s should be going for care!), we wouldn’t even have to have this argument about where the money is supposed to come from to pay for universal coverage! Let’s pray (!!) wiser heads prevail as they did in November!

  7. Duchess says:

    I fear there is something wrong with the way many people might think about your statistics.

    What has been pretty clear to me, living for 30 years under a system of government provided health care, is that if I compare what I have had to an insured person in the US then I have had a quality far, far below. I accept that what I have lacked in Rolls Royce service means that everyone gets basic service.

    It seems to me that you Americans are going to have to wake up to the possibility that you can’t afford to give the very best care (what well insured people are used to) to the whole population. Something has got to give.

    Your per capita spend in the US is twice what it is in the UK. Of course a small percentage are gobbling up all the spend. But the gobblers are living well and long, whatever your general statistics say.

    Oh and by the way, it looks to me — purely anecdotally — that those of you on Medicare are getting a whole lot more than UK pensioners too.

    It is not a simple problem, that’s all I am really saying. And some people are not going to like the solutions if real change comes.

  8. dale says:

    I think there are a couple things systemically wrong with American health care. One is that, so long as there are multiple risk pools (i.e. many insurance companies) the best way to make money will be to insure the healthy people and avoid insuring sick people. Competition will reward those companies that make the best guesses about who will get sick, and avoid insuring them.

    The other thing is that the incentives for bringing costs down never come down to a negotiating between consumer and provider. The trade-offs are all wrangled in insurance company offices and state legislatures. So health care is uniquely insensitive to what consumers want (who cares? It’s what insurance will pay for that counts) and health care end-consumers are uniquely insensitive to what things cost (who cares? the insurance is going to pay for it.)

  9. Darlene says:

    You make very good points. Thanks for re-posting your explanation of group care because it’s very important that people understand that it’s an insurance program that makes a profit. I hope Obama does not settle for that just to get something done.

  10. Mage Bailey says:

    Thank you so much for this. I’m signing up for Medicare in January, and doing as much as I can to unconfuse myself. Gee……what a mess. Right now we have the same insurance we had before just as COBRA….which only lasts 18 months. What a gift that is.

  11. Celeste Maia says:

    Thank you for such a good entry, so many good points.

    For years and years I had one of the “good” health care programs. My husband was in the Foreign Service and our family was covered with a program that worked anywhere in the world, was heavily subsidized by the government, and was backed up by military health care when we were stationed near US bases.

    When he left the Foreign Service and went to work for an international organization based in Spain, it was still good for a while. However, by the mid-1990′s, it all began to change. The euro-dollar exchange rate increased the dollar costs. The insurance company adopted a policy of questioning to death every bill so that we would simply be worn down with correspondence that never got resolved. In the event, the only bill the insurance company would pay was for the annual checkup. And we were paying $3,300 a year.

    We finally opted out of the US health care system — and that got the insurance company’s attention! For about the same amount of money — and no subsidies — we get excellent health care in Spain, elsewhere in Europe and even from the US. It is straightforward. If we use MAPFRE doctors and facilities, and there are hundreds, we just show our card and forget about it. If we use others, they pay 80%. We choose.

    This is the long way of describing how broken the US health care system is. Obama’s plan is not radical enough because bringing down health care costs will require undoing the unhealthy structures throughout the system. And that will take time. We will need that Advisory Committee to keep the focus on changing the economics of US health care down to its unhealthy roots.

  12. Mage Bailey says:

    I came back to re-read this, and am reassured that yes, we are not taking care of our people. I really appreciate you for writing this.

  13. I might say it is very important to the us government the health insurance coz every people depends their security for it not just us country but it must be implement to other country also….

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