Hitting the Cap, Exposing the Gaps
Today’s Washington Post explores lifetime benefit caps, provisions of most private health insurance policies that limit the total amount of expenditures an insurer will pay, with these limits typically falling in the one- to two-million dollar range. These lifetime caps and other insurance gaps like high out-of-pocket maximums and uncovered medical services are colliding with escalating health care costs to force questions about just what it means to have health insurance anyway.
Last year, in the follow-up to some research on medical debt I worked on while at Demos, I briefly met a woman who began putting her young son’s medical expenses on credit cards when her family’s insurance policy maxed out due to the costs associated with ongoing care for his chronic condition. Her situation was rare, as are the cases profiled by the Washington Post, but part of having insurance is knowing that you won't be financially ruined if severe illness strikes. Or perhaps not.
A few years back, the Institute of Medicine released a series of reports that painstakingly analyzed the importance of health insurance in accessing health care, highlighting the myriad problems that result from uninsurance, both to individuals and to society. We know that health insurance matters. Thanks to a growing body of research, at the heart of which is Professor Warren's findings on medical bankruptcies, we also know that, while insurance is crucial, it isn't always enough. Even the insured can face barriers to care and bills that exceed their ability to pay. The Washington Post article notes that the National Hemophilia Foundation is embarking on a lobbying effort to increase the amount of health insurance caps. If we move down the road of health reform in '09, we're going to wrestle with questions about how much individuals should be expected to pay and how much insurance should cover--questions we haven't exactly built a consensus around as a society but which threaten to fracture the public support that is building for health reform if left unaddressed.
There needs to be some understanding of not only how much money is spent, but on what.
Too much money (relatively speaking) is devoted to extending the lives of terminally ill people. The recent case of the young woman with leukemia who wanted a liver transplant is a good example.
Now that deaths in childhood have become rare people think that medicine can cope with anything and therefore, everything should be tried. The same thing is true, to a lesser extent, with older terminal patients where emotional bonds from family members make for unwillingness to just let go. The medical fraternity is also partially responsible, many see a death as a failure on their part.
Now the situation with those who have chronic conditions which require expensive treatment is different. This may also end up costing a lot of money, but there is a difference to living longer and delaying dying.
Another factor which clouds the issue is that the value of a life treated using expensive procedures is never factored in. How much economic activity have Bill Clinton and David Letterman generated since their bypass operations?
Before this option was available they would have become permanent invalids ("weak heart") and lived a constrained, shortened life. From an economic point of view the money was well spent, but it doesn't show up on the balance sheet.
--- Policies not Politics
Daily Landscape
January 29, 2008 6:14 AM | Reply | Permalink
Hmmm, the typical argument that conservatives make about health insurance is that it should be catastrophic in nature and that minor expenses should be paid by the patient with insurance coverage only stepping in for the big things.
But that only works if there are no maximum payouts.
The existence of maximum paysout says that you're not getting true catastrophic coverage for your premiums. Meanwhile, the existence of high deductibles says that you're paying out of pocket for most, if not all, of the little things.
So, as you ask, what is it that we're buying when we buy health insurance? It rather seems like a bum deal.
thosethingswesay.blogspot.com
January 29, 2008 6:23 AM | Reply | Permalink
So, as you ask, what is it that we're buying when we buy health insurance?
well, "health insurance" isn't enough since most folks would also need "income protection" as well. i.e. if you get really sick, you could lose your job and current health insurance plans don't help those who have income disruptions.
the main disadvantage to "catastrophic insurance" is "lack of preventive care."
i.e. "catastrophic insurance savings" won't materialize if preventable problems turn into nightmeres.
To boldly go...
January 29, 2008 10:32 AM | Reply | Permalink
You confuse by using quotes when they are not called for. You are not quoting, and you not implying that the term is inappropriate (as in "so-called").
If I read this post using accepted usage rules, I would be hearing "so-called" in front of every quoted phrase.
January 29, 2008 4:19 PM | Reply | Permalink
i'm using the quotes in the "so-called" sense since the phrase "catastrophic insurance," for example, is vague (ill-defined) and nothing more than a concept.
i.e. if you saw me write the post, you'd see my fingers flapping like bats as I was "quote/unquoting."
i.e. even the term "health insurance" is vague since low wage employees, for example, might "have insurance" techically but-- due to their incomes, can't use it because of the required copays and deductibles.
To boldly go...
January 30, 2008 5:16 PM | Reply | Permalink
When every important term in a discussion is qualified, uncertain, a stand-in, what the hell can we talk about?
For example, there is a very precise type of insurance called catastrophic insurance. Its terms and conditions will be spelled out in bunches of fine print. Because its provisions are not necessarily well understood by people does not mean there is anything vague or ill-defined about the insurance. It is not merely a concept.
Your use of quotes is sometimes referred to as scare-quotes.
BTW, "i.e." means "that is", so I don't get why it follows from vague concepts that you type fast. Suggest slowing down, and editing.
Lesson ends, I won't quibble anymore.
January 30, 2008 5:27 PM | Reply | Permalink
Thats a value judgment. We are all terminal. And yes, those that are the sickest (so sick that death may be close) consume more medical care than the young and fit. We see this lifeboat mentality in the UK where the NHS is looking at no longer providing services to those that are "too old."
I'd rather have a lifetime cap in dollars than a cut off age. Or for that matter the Canadian system where every one is ensured, but they skimp on capacity so high resk births for example are routinely sent to the US.
The sons of the prophet are noble and bold,
and quite unaccustomed to fear.
But the bravest by far in the ranks of the Shah
was Abdul Abulbul Amir
January 29, 2008 1:03 PM | Reply | Permalink
Can you cite any sources for you claims as to how Canadian and UK health care policy decisions are made, or are you just repeating talking points that are floating around.
I did not speak of people being "too old", but "too sick". Composer Milton Babbitt just had a premier of a new composition of his, it was timed to coincide with his 99th birthday.
There are no plans which cut people off for being too old. There are limits on what sorts of procedures will be undertaken, but even this is changing. For example, hip replacements are now being done on people in their 80's who used to be considered too frail. Being able to walk for a few more years is a big thing.
All medical care is rationed. In this country it is rationed by the ability to pay, rather than by medical necessity. No one is ever going to be satisfied if they are told that they are being denied treatment because it isn't worthwhile, but sometimes it's just the truth.
--- Policies not Politics
Daily Landscape
January 30, 2008 7:05 AM | Reply | Permalink
Yes to hips for 80-yr.-old folks. My mom works full time as a music teacher, used to walk a few miles every day, and had to stop with degenerating hips. Finally got one a couple of weeks ago, is back home and walking with walker, will be fully mobile in two months.
Out of hospital in three days to resident rehab for 1 1/2 weeks. She is in excellent health and likely to live into her 90s.
Got her hip through Kaiser Permanente, in MD.
Then again there is the fellow I know, who is hugely overweight and diabetic, who just got two knees.
January 30, 2008 7:33 AM | Reply | Permalink
A pure age limit isn't, IMHO, the way to go. The ethics get complicated, but assessing the patient's overall health and likely benefit makes more sense.
Diabetics (and I am one) have an additional problem. With the exception of metformin and exenatide, all currently approved medications for diabetes cause weight gain. Most of them, including insulin, reduce the danger of circulating high sugar and byproducts by forcing the sugar into resistant cells. Unfortunately, the cells now have an excess of sugar and produce fat.
There has been quite a bit of significant research about new classes of drug that may be able to stop the weight gain, some in fairly advanced testing. We may be seeing ways to bring down weight and make things like knees more appropriate.
In Houston, one 98-year old got definitive surgery for an aortic aneurysm, which normally would never be done for someone that old. Since the patient was Michael DeBakey, and he invented the procedure, it seemed only fair to make an exception. After close to a year of rehab, he's back to leading cardiac surgery (I don't know if he still does hands-on surgery, but he certainly teaches). His diet seems to consist of Snickers bars and cigars, but he does run up and down the stairs.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
January 30, 2008 7:50 AM | Reply | Permalink
Here's a novel idea: tell the health insurers to go pound sand and nationalize healthcare.
Anything else revolves around the notion that it somehow makes sense to pay 35% more than citizens in any other first world nation so the insurer can not only afford to hire people to comb through your records looking for excuses to deny payment but can also pay the CEO tens or hundreds of millions per year.
Yeah, that makes sense - if you're a health insurance company or one of the politicians they own. For everyone else, it just means you pay more and you may or may not get care, and even if your insurer is feeling magnanimous and covers the costs up to the cap, you may still end up losing everything you've worked for your entire life.
Every one of the "expand access to insurance" plans has the same fatal flaw...which is, no one can explain the mechanism by which the government can force a private business (the insurance company) to accept all comers. It's a pig in a poke, it won't work, and it will only prolong the immoral horror that is the "health care system" in this country. We're fast approaching the point where the majority will be uninsured...certainly less than 10 years from it. And maybe that's what it will take...maybe the whole system will have to come crashing to the ground and the insurers will have to be bankrupted before our "leaders" will wise up and recognize that as long as there is a profit to be made from letting people die, people will be allowed to die. Though it would be a shame for all those folks who will lose it all or die over the next 10 years before we reach that point.
January 29, 2008 3:28 PM | Reply | Permalink