Closing the Gap

drethelin:

slatestarscratchpad:

The longer I work in medicine, the more convinced I am that universal single-payer health care is the way to go.

Yes, I have several great ideas for innovative private health systems that would solve all our problems for cheap, just like you do, but these will never happen, and if we wait for people to look into them we’ll be stuck with our current system.

And the main thing I’m learning from working in medicine is that the current system is crap. There are some problems everyone’s already priced in, like how poor people can’t afford it, or like how it keeps prices high. I’m talking about other, new and unexpected forms of crappiness that I wouldn’t have predicted. Like:

- Poor people have weird issues traveling out of state. Medicaid is handled by state governments, so if you live in Nevada and take a vacation to California, and get sick while you’re in California, sometimes California just decides not to treat you because you’re on Nevada insurance and they don’t want to deal with that.

- Likewise, if a poor person wants to move from Nevada to California, there’s going to be a gap until they can jump through the hoops to get California insurance. During that gap, they will not be covered. There are things they can do to retrospectively get covered by California after they have gotten California insurance, but this is a scary gamble for some people.

- There is a constant problem where someone has a therapist/doctor they have worked with since forever who knows all of their problems inside and out and has a great relationship with them, and then they change jobs, and their new job only offers Aetna insurance and their doctor only takes Blue Cross insurance, so they’ve got to find a new doctor who doesn’t know anything about them. In the modern economy people switch jobs every couple of years, so I have patients who have never really formed a good relationships with any doctor because they know they’ll just be forced to see someone else later.

- Likewise, I have some patients who don’t want to start something important like trauma therapy or a new medication right now, because they’re afraid they’ll have to switch jobs soon and all of their treatment will end up in limbo, so they just end up getting inadequate conservative maintenance treatment forever.

- I have patients who could easily support themselves with a part time job, but who have to work full-time in order to get health insurance. I have patients who could easily support themselves off of an inheritance or something like that as long as they worked hard to budget their limited money, but who have to work full-time in order to get health insurance. I have patients who could easily support themselves with some kind of self-employment, but who have to work for a big corporation in order to get health insurance.

- The law says kids can be on their parents’ insurance until 26, which is great and a lifesaver for a lot of people. But parents don’t have to keep kids on their insurance if they don’t want to, and this gives abusive (or just overprotective) parents a huge lever with which to control their children’s lives, over and above normal financial dependence. I’ve seen this go really badly.

- I have some patients without insurance who pay out of pocket to see me once, with wildly inflated expectations of what I can do in a single visit. Then when they learn not all their problems will be solved immediately, and they freak out, because they can’t afford to see me more, and actually it was a huge financial stretch even to see me just once, and now that money has been wasted because I didn’t solve the problem they needed solved.

- Lots of my new patients come in with a story like “So I was doing great on medications, until there was an issue with my insurance, and I couldn’t get them for a few months. Well, two years and twenty hospitalizations later, here I am, sane again, and now I want to be put back on the medications that I know work for me.”

And these are the lucky people, the people who do work good jobs and end up with some decent insurance most of the time. Everyone else is even worse.

Don’t subsidize the tulips

Actually, I don’t think the obscene costs of medical care are tulip subsidies, but obscene risk averseness. Each % reduction in accidental injury or harm comes at double the cost of the previous %, we start at 80%, with a 10% cost increase for the first % drop; by the time we hit 90%, we’re paying 2x the cost of 80%; by the time we hit 95% we’re paying 17x. The exponential cost is because we’ve already exploited all the low hanging fruit, so we have to add more and more expensive safety procedure to get the same effect as before.

Every mishap gets a malpractice suit, insurance premiums go op, hospital policy adds more time-consuming and distracting work to already overworked staff, regulatory agencies demand said policies, net work per inflation-adjusted dollar goes down, cost of medical care goes up. Keep doing this for 50 years, and you have stupidly high cost of care. And since medical care isn’t exactly something you can opt out of (I mean, you can, and people do, but you mostly don’t cause it’s kinda important, though understandably not as important as food or shelter) people just sort of have to pay these ever-growing fees.