Let's care about folks who can pay
May. 22nd, 2019 09:41 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
mprotsenkoI had a discussion recently about different types of healthcare system. Heard a very honest argument along those lines (not verbatim so I may misinterpret it but I do hope I summarize in the right way):
- Yep, the poor are screwed, but what about those who can pay? Shouldn't we care about them too? Does it make sense to prioritize that care? If we start caring about poor, others will suffer and that's bad.
Well, a couple of months ago I took part in a fundraiser. People were collecting money for a software developer (a friend of a friend of mine). Why? After all, if you work in Facebook, you get the best health insurance money can buy. If you work in Facebook - you are not poor, you belong to top 1-5% incomewise. He must have done something really wrong to screw things up so bad he needs to beg. It must be a poor decision. It will never happen to us. Right?
Well, wrong. Turns out - if you have a cancer, if you're too sick to work, you lose your job. After a certain period of time, your disability insurance stops paying - since you're "healthy" enough to be doing something (even if this something is paying 10x-20x less than your last job). You still need to make your mortgage payments (your kids need to go to a good school, right?), but you also need to travel out-of-state to a clinic that specialized in your type of cancer (and pay out-of-network copays and deductibles). And you need to rent another place to stay during your treatment. Ah, and in addition to that you need to make insurance premium payments (fortunately, due to CORBA you get to keep your insurance - but you still need to cough up several thousands dollars a month).
So if you think that a single payer system only benefits poor people - think again. When you are going to become sick (not if, when - it is a matter of time for all of us) - it is going to become about you, not about poor people. (Unless you have a few hundred thousand dollars stashed away.)
The only lucky break here is that you can be old enough to qualify for an existing single payer health coverage (Medicare, yep).
- Yep, the poor are screwed, but what about those who can pay? Shouldn't we care about them too? Does it make sense to prioritize that care? If we start caring about poor, others will suffer and that's bad.
Well, a couple of months ago I took part in a fundraiser. People were collecting money for a software developer (a friend of a friend of mine). Why? After all, if you work in Facebook, you get the best health insurance money can buy. If you work in Facebook - you are not poor, you belong to top 1-5% incomewise. He must have done something really wrong to screw things up so bad he needs to beg. It must be a poor decision. It will never happen to us. Right?
Well, wrong. Turns out - if you have a cancer, if you're too sick to work, you lose your job. After a certain period of time, your disability insurance stops paying - since you're "healthy" enough to be doing something (even if this something is paying 10x-20x less than your last job). You still need to make your mortgage payments (your kids need to go to a good school, right?), but you also need to travel out-of-state to a clinic that specialized in your type of cancer (and pay out-of-network copays and deductibles). And you need to rent another place to stay during your treatment. Ah, and in addition to that you need to make insurance premium payments (fortunately, due to CORBA you get to keep your insurance - but you still need to cough up several thousands dollars a month).
So if you think that a single payer system only benefits poor people - think again. When you are going to become sick (not if, when - it is a matter of time for all of us) - it is going to become about you, not about poor people. (Unless you have a few hundred thousand dollars stashed away.)
The only lucky break here is that you can be old enough to qualify for an existing single payer health coverage (Medicare, yep).
(no subject)
Date: 2019-05-22 06:57 pm (UTC)(no subject)
Date: 2019-05-23 08:00 pm (UTC)(Actually, I wonder, is a current startup culture viable for anybody except fresh grads, children of affluent parents, who still enjoy their parents insurance and a safety net provided by their family and friends. I guess it is hard to innovate from dusk till dawn in "all or nothing" mode when you have to look after your sick mother or take care of younger siblings.)
(no subject)
Date: 2019-05-23 10:28 pm (UTC)(no subject)
Date: 2019-05-22 11:48 pm (UTC)(no subject)
Date: 2019-05-23 12:32 am (UTC)But your example is still an example of someone who fell out of the category of people who can't afford the health insurance they want. He _was_ working for FB but isn't any more. One one hand, this example is aligned with my self-reasoning when decided to myself that universal healthcare might be the lesser evil. On the other hand, it creates more problems than it answers. The two key structural components of the problem here are:
(a) we are talking about unusually high-cost care (out of state treatments etc) not covered by most insurances. That is, most regular insurances won't cover it. Which means, likely, that universal insurance might not cover it either.
(b) the person we're discussing (I with him the best and feel terrible about this third person discussion, but playing devils' advocate is a hard job) cannot afford those payments because (or at least partially because) he choses to maintain his residence in the area that off limits to people with way-lower-than-FB-employee pay range.
Basically, to an external observer X., who could be almost everyone in this country, you are painting a picture of someone who until recently could afford living in this fancy place and having this fancy health plan, which X. is likely to never be able to afford anyway. And then through unfortunate illness, that somebody lost the income... but still continues to live in this fancy place and wants to be able to afford this fancy care... I don't see how such rhetoric is going to sway anyone the right way. Hell, as someone who's been a poor scientist until quite recently and never able to afford mortgage payments in a municipality with good schools for my kids (even now I can only afford rent payments, but not mortgage, in a place with relatively mediocre schools), I don't see anything constructive in this example.
Reminding again, that on a personal level I fully sympathize with the situation: last year I was laid off and unemployed for a few months and had to buy insurance for a family of four directly, so trust me, I know the prices for good insurance. On the other hand, remaining able to pay for a good health plan is one of the reasons why I can't commit to mortgage payments or higher rents, so yes, I can't _fully_ relate with someone who is able to and decides to continue to pay off a house in South Bay or Peninsula.
Long story short, it's not a good example for your cause and might be actually a counterexample from some points of view.
(no subject)
Date: 2019-05-23 01:02 am (UTC)And that is not an unusual scenario - serious illness is a matter of time for each and every of us. The only way to get lucky - is to hope that it hits us when we are enrolled in a single payer system.
And you don't need to have a mortgage or out-of-state treatment to get screwed. Let's imagine a poor scientist who rents a modest apartment in a decent neighboorhood so his kids have a shot of good education.
This imaginary scientist loses a job - you cannot work as a scientist if you cannot concentrate, have a fever and vomit a couple times an hour. However, after a small period of time the disability insurance tells that scientist to screw himself - he can work as a part-time data entry operator. Or he can knit socks. Or whatever. So no income for him.
Now he's facing about 5-10k a year in copays and deductibles. He has to pay around 2k each months for his modest apartment. And he has to pay 1500-1800 each month to keep his insurance. (Less expensive insurance may be not an option - a hospital can choose to not accept it or you will have to cough up extra dough in copays and deductibles.)
Can you please explain what choice can this imaginary scientist make ends meet? And how can he avoid this situation? What choice should he make to avoid that?
(I understand the desire to close the eyes and say "That cannot happen to me, I am young, I am healthy, I will not get sick". But the problem that it SHALL happen to you. The question is not "if", it is "when".)
(no subject)
Date: 2019-05-28 10:31 pm (UTC)The fact that these questions were left unanswered - seems to be itself an answer.
(no subject)
Date: 2019-11-21 07:21 pm (UTC)(no subject)
Date: 2019-05-23 01:06 am (UTC)A care with low copays that has your doctor in network is not fancy - it is a necessity WHEN YOU ARE SICK. (Otherwise you can face an extra 5-10-50K in payments or be denied care you need.)
When you are healthy - of course, it looks like something you don't need. As of keeping a fancy place - can you please describe, what steps you need to take to sell your house this winter in Bay Area?
(and even if selling house was an option - are we seriously discussing choosing between good education for your kids and getting life-saving care? playing devil's advocate sometimes can lead you to a place you won't be comfortable to be in.)
Ask yourself - what would happen to you and your family if you got seriously sick between jobs? What choices would you face and would you be able to face them without going through disaster of one kind or another?
And let me remind you - being seriously ill (to a degree of not being able to work) is something that we are all going to face.
Valar morghulis.
(no subject)
Date: 2019-05-23 04:37 am (UTC)Of course. When you are sick you want the care that would give you the most coverage and the least copays. There are plans like that, they cost way more than plans with high copays and no out-of-network options. That's why I'm calling the former fancy. You can call it better or whatever you want, the bottom line is the same: the plan is ready to pay you more when the time comes. Clearly, majority of people who could never afford this more expensive and fancy plan are not going to sympathize with someone who had it, lost it, started making as much as they are making, but wants to be able to keep the old benefits. So I don't see what is your problem with this part of my comment.
Unless the whole problem is that even a cheaper plan should offer all the same benefits. That's a good plan but hardly realistic. The only way to make people pay more for the same options they can get for less is force them to pay not an amount but a fraction of their net income or net value... but I don't believe that would be possible in the US any time soon, and even if there's a law along those lines, it would be really abused, based on how people pay taxes or whatever.
The alternative is having a _basic and simple_ care guaranteed by any coverage and then having the rest cost extra. But the problem is that this would not solve a problem you described: basic and simple by definition cannot include _everything) so as soon as you have something that needs a non-basic care, you're back to where you started.
> ...Ask yourself - what would happen to you and your family if you got seriously sick between jobs? ...
... let me remind you - being seriously ill (to a degree of not being able to work) is something that we are all going to face.
Tell me about it. And we haven't even scratched the scarier diseases like psychiatric disorders or all kinds of dementias. I have to worry about same + the kids. And in the last four years, I shopped for a self-paid health plan for my kids a few times, twice paying out-of-pocket, and always chose the fancier options but in all cases that came at some expense.
> if selling house was an option - are we seriously discussing choosing between good education for your kids and
> getting life-saving care?
I know people who are making these choices daily. Including myself, to some extent. In your example I can only guess, but I can infer that the "good education" implies living in the area that is off-limits house-wise to more than nine out of ten Americans. The inhomogeneity in school quality is way less than that in real estate. Which means that you can get a slightly worse school having to pay half the money in mortgage or lower rents. Or lower rents on way worse housing right there: I know people staying with kids in tiny apartments in Palo Alto just for that.
> ... steps you need to take to sell your house this winter in Bay Area ...
I don't have a house to sell. I know that renting out a place takes a few days. ALso know that there was an open house next door for a 100-year no-thrill old house with two tiny bedrooms, we knew the agent, so stopped by to check. Within half an hour from coming to market the price went up by $250K from the starting $1M.
Again, I am not saying that any time you get seriously sick you have to end up on the street, but since for most people in this country these prices and these locations are so out of reach in the first place, mentioning this whole thing here make your argument counterproductive.
(no subject)
Date: 2019-05-23 07:17 pm (UTC)My problem with word "fancy" is that it sounds like something unnecessary, something you can live without.
- A cheap beat-up truck moves my ass from point A to point B the same way my fancy plug-in hybrid does.
- A cheap homemade meal has the same nutrients as a meal in a fancy restaurant.
- Cheap jeans cover my butt the same way D&G clothing does.
On the contrary - "fancy" care means getting access to specialized care that literally means difference between life and death. Or at least between financial catastrophe and normal life. That's not fancy for me, that is necessity.
I don't want to go into details of survivor bias - the same house can be sold for 20% above listing price or 5% below (depending on market condition/time of year). Sometimes it means losing money (even if you sell it for 10% over asking prices - agent commissions, taxes etc.) Unfortunately, you usually don't get to decide "okay, the market is hot right now, it is a good time to get sick and sell the house."
Tthat is not important. The important question is:
Would you be able to survive a severe illness that leaves you unable to work for months or years without going through financial ruin and jeopardizing future of your kids?
P.S. Can I remind you about Canada numbers (speaking of different). I am really curious how did you come with conclusion "Canada is worse when it comes to healthcare" - because I did the same math and the only scenario that works better for me in the US is "I stay lucky and healthy and don't need a lot of healthcare before retirement."
(no subject)
Date: 2019-11-21 07:25 pm (UTC)not in USA
(no subject)
Date: 2019-05-23 10:49 pm (UTC)What about canceling a lease? Did you know that a standard contract have you responsible for paying the whole amount till the end of your lease? So if you have a 1-year lease and decide to move out 2 months into it - you are still technically responsible for 10 months of payment.
(There is a law trying to soften that blow so landlords usually end up accepting several thousands dollars to let you go off hook to avoid a legal battle - but that works only if you can afford a lawyer.) I went through this process last year. It is funny how you forget about this fine print until it hits you personally.
The alternative is renting month-to-month but I do have a feeling that you have a standard 6-month or 1-year lease (as the majority of other Bay Area renters).
(no subject)
Date: 2019-05-24 12:46 am (UTC)Your other conceptual examples that smth like that could happen to a lesser income person are better. Less personal, because they are hypothetical, but still.more relatable.
(Will use this comment to bunch up a few other points in our conversation, happen to have a few min now while the build is building :)
By "fancy" I did not mean "unnecessary", necessity is orthogonal. I meant advanced+expensive, so independently of necessity, not available to all.
Can't comment on your example from LA.. But can hypothesize based on two cases that I witnessed very closely. Which would possibly explain why some people might think that way, So, to patient cases, both in 2004, before Obamacare. Both involved a person getting into a terrible accident and ending with a person in ICU. With multiple surgeries, constant fancy (in a sense expensive and advanced) diagnostics. etc. Both survived, one after three weeks in ICU and several cutting-edge image-guided interventions, never got off the wheelchair after that, but got 10 more years of life. The other spent two months (!) in a coma on advanced life-support, never regained all of his cognitive skills, but lives on. The first person had to sell his business and his (fancy and expensive) house to pay for it, the second had to give up his mortgage and declare bankruptcy. Neither would like to lose that... but on the other hand, the level of care (by total cost etc) each of them got was so high that it is likely to not be available for just anybody. In the second case, I'm almost confident he wouldn't survive any triage approach: they wanted to turn him off the system quite a few times, his mom had to fight hard for his life. So the reason people might want to stick to current healthcare is this hope that when they really need it, they might get this kind of help that is only available here, but not in those socialized medicine places. To hell with it if they have to go bankrupt after that, life's more important. Now, neither you nor I know for sure if this kind of would have been available under a different system. But as long as there are examples of US healthcare, at least in some instances, being ahead of the rest of the world, such scenario remains realistic. As the fear of hitting such scenario remains a legitimate fear.
So my point is the following: first, I wouldn't be too condescending to the people who are trying to keep the current system, as they might be hedging against different risks that you or I. Second, until proponents of universal health-case genuinely address this issue, they are not likely to persuade the other side. Know thy opponent :)
(no subject)
Date: 2019-05-24 09:18 pm (UTC)This discussion is not an attempt to persuade anybody. I believe the time for persuasion is long gone. The data is out there, the personal examples are out there - but they cannot compete with propaganda because propaganda doesn't deal in logic and metrics.
And I am grateful to you for providing an illustration, for showing how "some of the people may think". I bet you have similar stories that took place in single-payer healthcare systems (or can easily look them up that). And you've seen similar or better outcomes minus the financial ruin.
(I actually have witnessed a similar story - my friend's mother was hit by a car in Canada and went through similar ordeals - several weeks in ICU, image-guided surgeries, prolonged rehabilitation - but there were no bankruptcy or financial ruin. On the contrary - her rehabilitation went much better partially because she didn't have to deal with financial issues while recovering. Yep, not having to choose between getting PT or selling your house actually helps.)
But you've shown us pretty well that no statistics or counter-examples will change the way "some people think" because for them is not about statistics or anecdotes. They will always find their example they will cling to, ignoring counter-examples, statistics and other arguments. Because they can always say:
- your examples and your statistics prove nothing
- we never can be 100% certain
- there is a risk that for 1 person in a hundred million the changes will you propose will make things worse
- there is no truth,
...and there is nothing you can do with this line of defense.
You cannot convince people that God doesn't exist (or does exist) using logical arguments. It is the same here.
And that is not true. I do know that that kind of help is available under a different system. I have personal examples, if you haven't them - you can look them up really easy.
You can see affluent US doctors/politicians going to Canada to get their surgeries done.
You can look up statistics.
And finally, nobody can stop you from getting the best available private care even under single-payer system (paying out-of-pocket or using a private insurance).
It has been addressed over and over again (I just did, for example) - but the opponents keep choosing to ignore that. So it does helpful to know the opponents, but I don't think we have a lot of opponents that are acting in good faith.
So this post of mine is not about convincing right-wingers. Hence, it's productivity shouldn't be judged by that metric ;)
(no subject)
Date: 2019-05-28 06:21 am (UTC)> ... This discussion is not an attempt to persuade anybody. ...
Well, then I misrepresented your original point, where you talked about adding efficiency as yet another obvious argument to the healthcare debate. Mea culpa, after that I treated your points as persuasion arguments (what's the alternatives, self-persuasion?) So by now my point is not only to show how "some people may think" but to comment on your arguments. I'd say this: had I been undecided on the healthcare approach I would be persuaded by them: solely because while some of them are OK, the others are counterproductive. Lemme know if you care to hear why ;-)
Still, just to wrap up a few earlier points where I thought you left hanging questions to me:
> personal choice Canada vs US on healthcare.
Yes, when I was making my choice I did indent to have a job in either country (without a job I'd be gone out of either, so simple choice here), but no, I did not plan to be healthy. As a matter of fact, I was making the choice at the time when my wife was going through a complex treatment with multiple diagnostic procedures, therapies, and a surgery. I was working at a major university hospital in the US and considering either a major research hospital in Canada or a National Lab in the US. The latter won, both in specs and in private polling between a bunch of friends and colleagues who switched countries one or another direction. Both in near-medical research settings and in private business like coding. So while I agree that when you have no job or a bad one, Canadian system would be better, but until then not really. BTW, funny, I formed that opinion back then comparing specific health plans and talking to live people Just now, writing this, I looked up the stats, and found quite a lot of supporting statistics. Just read a WaPo article from 2016 on that. The article is debunking Trumps lie about Canadians coming in droves for US treatments but the data they quote aligns 100% with what I have been hearing back 15 years ago: you have to wait longer, sometime ridiculously long, for appointments deemed non-critical by someone other than you.
> ... high consumer spending and you shrugging it off as victim blaming...
You gave a few examples about how a poor person might need a truck to haul, how everything's so far you can't get by without a car or how they get cheap used trucks. But despite all of those things being possible, they don't make up the statistic, and this one one argument that I made about stats: not to state that anyone can afford the medical bills if s/he lives more frugally (wrong) but that if people lived more on-par with those other single-payer countries, that would free up much $, which could sway the terrible healthcare involvement statistics you started up with. It's not about sheer amount of dollars, the purchasing power does differ, its about bulk of consumed goods. Don't want to re-look-up links (I check on my phone some days ago) but if you care, just check out "list of countries by *" categories on wiki or elsewhere. Americans do have one of the biggest ecological footprints, consume consume most food ( by calorie and by meat content), have the most square feet per person, use up as much energy as the top spenders, same for textiles, cars, movies seen in theaters, or home electronics. Far ahead of anyone else in terms of guns and ammo (those things cost a lot, btw). Most of those statistics take everyone to contribute to, not just the top 1% or the top 50%. Say, the aforementioned trucks: they are not the cheapest vehicles possible, especially to use. Yet more than 50% or personal vehicles in the US are trucks. And I haven't checked how much of the remaining fourty-smth % cars are SUVs, but sure that of the new ones it's more than half. Are 3/4 of Americans in the business of regular hauling? Or are just way too many people spending way more than they should on their cars following fashion and clever marketing campaigns. So, if there could be a way to blame the society, not single people, I would be totally blaming the US society on wasting money on personal stuff instead of better things.
Myself, I think that the problem with healthcare in the US is not that it's bad, for many it works out fine, that's why it's so hard to change the thing. The problem is specifically (the good argument among the ones you used, but didn't follow through) that the most basic guaranteed care (Medicare) here kicks in only after you've lost more that you have to lose. And then the obvious conclusions etc... But effectiveness and fairness are not always supporting the argument in the obvious way, by far.
Anyway, time to go again
(no subject)
Date: 2019-05-28 06:56 am (UTC)Longer waiting times for non-critical care don't make people happy - but are there any numbers to show that they worsen the medical outcomes? I have a very fresh example of the contrary - I just got my knee scanned. The waiting time was about 7-10 days. They found some inflammation and a minor ligament tear - which I lived with for ~20 years. If the waiting time would be about a year - there would be literally no change in the outcome (and they could have spent time and money on diagnosing/treating people who actually needed care, not on some grumpy guy with a moderately injured knee).
Can you please prove it? You made only one verifiable claim - about 50% of personal vehicles being trucks.
Let's look it up.
https://www.eia.gov/todayinenergy/detail.php?id=36674
As far as I see, trucks make up about 16% of total cars sales, that's not even close to 50%. And we see that cars and crossovers - which are much more fuel-efficient that SUVs - make up the majority of sales.
So I don't know where you got your data from - but it is not confirmed neither by other data nor by personal observation (really? more than 50%? try counting cars next time you stuck in traffic and you will see that "more than 50% of vehicles are trucks" - well, how do I put that mildly? - is not even remotely true). The only way to get to 50% is to lump up trucks and SUVs into one category and then count the market share by dollars, not by cars sold or owned.
But that would be a dirty trick and I cannot imagine you stooping that low. It seems like someone fed you the false data.
So pardon my lack of trust, but I have no reason to accept the rest of your statements on that matter ("poor people make poor spending choices instead of spending money on healthcare/education") without any proof. At least not until you bring the data. (And by data I mean full distribution chart, not just the average number - since top 1% can skew up average numbers pretty bad).
The same argument could have been made by Marie Antoinette. Indeed, the system worked really well not just for her but for a lot of other people as well. Until it didn't. But you right - it was hard to change it even then.
(no subject)
Date: 2019-05-28 07:06 am (UTC)So unless you get seriously sick (and thus cannot work), Canadian system works better.
If you get mildly sick or don't get sick at all - the US system works better. (though it is 2-4x more expensive)
And many people have that illusion that they don't get sick (or hope that when they will get sick, they will be old enough to be enrolled in the existing single-payer system).
It seems that we have no disagreement here.
Indeed, on a personal level, there is no sense in paying healthcare-related taxes or buying insurance until you get sick.
So those suckers who do buy insurance while healthy - will have to pay more (because the patients'/payers' pool is less healthy as a whole and thus have more expenses which insurance will have to cover). So some of them will not be able to afford it, and will drop out of the pool, driving the costs even higher for the rest. And so it goes...
Basics of game theory - in non-zero sum game you can make a move that provides a short-term gain to you, but you pay for it with a long-term loss to both you and your fellow player.
(no subject)
Date: 2019-11-21 07:31 pm (UTC)единственное по чему США впереди всех- это по ценам на медуслуги и затратам государста на медицину. затраты огромные, потому что цены огромные, и потому что много запущенных больных. которым помогает государство (пожилые, бедные, или инвалиды, или все вместе).