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I know people get caught up in compassion and don't want injured people untreated, and don't want indigent people destroyed by bills they can't pay, but it is so unfair to those of us who play by the rules.

We pay a mortal fortune (at least to me) for health insurance as my husband and I are both self employed.  We have a large deductible, but not so large that it would bankrupt us if we have to meet it.  We carry the insurance because we are responsible adults who recognize our obligation to provide for our own health care and the health care of our children.

What I don't like is the hidden tax on us to pay for all the people who choose not to do so.  It makes even the most compassionate mommy party among us to want to play tough.

This is just one more reason, in a long list of reasons, to enforce border security.

is better than this.  Still a tremendous waste of money, but better.

Those with legitimate needs for the entitlements our nation has been offering ever since FDRs programs were perverted by his legislature are few and far between and 'twould be better to put that burden on their families than to put it on EVERYONE's shoulders because you can't sort them out from all the Dolists out there.

It's the immigration...

But I'm sure the cheap strawberries more than make up for the inconvenience of non-functional emergency rooms.

....there were an awful lot of citizens without health insurance. It isn't JUST illegal immigration, though that is a big factor. As I posted earlier in other threads, both parties are completely unwilling to deal with this problem. The President has proposed what seems like a workable plan, but he hasn't pushed it at all and no one in Congress seems like he'll take it up.

Also, I hope you weren't suggesting that insurance companies are barely eking by.

It's the illegal immigration, which should be fought.  The solution is legal immigration, and more of it.

Legal immigrants can get jobs that come with health coverage; illegals cannot.

-TS

I hope you weren't suggesting that insurance companies are barely eking by.

Let me suggest this instead: you said that without knowing how they are doing, figuring that I wouldn't check. But I did. Why don't you hunt down a couple of health insurance providers, like I did, then come back and tell us about their stellar rates of return.

Can, in theory.  In fact, low-skilled, low-wage immigrants, who make up the bulk of the inflow, aren't going into jobs that pay benefits like health coverage.  Furthermore, the wage-lowering pressure (which you acknowledge, indeed tout, in other contexts) of increased competition for jobs will tend to reduce non-salary compensation like employer health coverage just as it reduces wages.

Who was Chief Resident and specialized in emergency medicine at a very large metropolitan-area hospital recently, and I'm going to email him the contents of this post to ask his thoughts.  I think he'd have some interesting things to say about it, but it might take a few days to get a reply, that's why I'll refrain from commenting more now, except that I think you're on to something.

It's surprisingly difficult to FIND rates of return for health insurers. They tend to be folded into huge financial services companies, and their individual returns aren't published. The three organizations that I instantly thought of that JUST do health care-- Kaiser, Group Health, and Kitsap Physicians-- none of them are publicly traded. (Actually, KPS was insolvent as of about five years ago, but seems to have recovered.)

I ended up hunting down Aetna and Prudential. I don't even think that Prudential PROVIDES health insurance plans.



year      Aetna       Prudential

2004       11.3%          8.0%

2003        5.2%          4.5%

2004      -12.7%          0.7%



Eh. Not bad, for a commodity business, which insurance surely is.

What -are- those numbers, and which year is 2002 improperly labeled?

As a practicing physician, and one who, while not board certified in emergency medicine, certainly has seen my share of emergency department patients, I have a slightly different view.

EMTALA, the Emergency Medical Treatment and Active Labor Act, is the 900-lb legal gorilla in this picture. And make no mistake, it's serious. If I, or any other physician in an emergency department, refuses to see a patient in need of emergency services because of their inability to pay, I can be held personally liable for up to $10,000. As can my institution, and that $10G doesn't include other civil liabilities.

Which is actually pretty much OK with me. I don't really mind taking care of a sick child whether or not their parents can pay me. I'm not in favor of women giving birth on the sidewalk outside a hospital because hospital rules won't let them in without insurance. And I know enough hospital administrators to know that while most are reasonable and caring, there are certainly idiots out there who don't understand the real consequences of stupid policies. When you're playing for real stakes, you can lose things that matter. EMTALA is a great club to wield when I need to actually practice medicine.

On the other hand, I can't go on seeing sick children if nobody can pay me. I rely on such gestures being occasional compassion, not business as usual. I have a family too, and we only eat if I can work and get paid for it.

How do we start to fix this? How about fixing the other stuff I have to deal with? If you can get my medical liability insurance down, you cut my necessary fees. If you can get the drug companies' exposure under control, you can dramatically reduce the cost of prescription drugs, making insurance cheaper and easier to get. Get rid of obsolete (but absolutely mandated) DRG and CPT billing and replace it with something with some sanity to it, and you can (over time) reduce everybody's overhead.

Tort reform would be fantastic. Immigration reform would certainly help. Either or both of these would suit me a lot better than returning to the pre-EMTALA state.

I have a feeling that my friend will have a lot of thoughts that mirror yours.

My father-in-law has been an ER doctor for the last 25 years, and his biggest complaint is the medical malpractice insurance (practices in NC, so thanks a lot John Edwards, you ^expletive deleted^). I don't know about anyone else, but paying 50% of my salary to insurance just so I could work is ridiculous.

Unfortunately we've built our system around it.  

There needs to be access to reasonably priced health insurance for all, even those with medical conditions.  Likewise, there needs to be some minimum level of health insurance which everyone is required to purchase.

Normally I'd be against that kind of government requirement, but the reality is someone's decision to carry or not carry health coverage impacts far more than just that person.

RE:  Medical Liability.  People need to realize that bodies are not cars that can be hooked up to a computer and diagnosed.  Until American jurists quit seeing someone in bad circumstances and giving them someone else's money, our business climate, including health care, will be poisoned.

RE:  Drugs.  I believe that if a producer gets their drug approved by the FDA, they should be exempt from any and all liability due to the use of the drug, unless they committed fraud in their FDA approval process.

RE:  Docs.  I am grateful that they are willing to see people on a charitable basis when needed.  Thanks.

Actually, it's quite easy to get the "rate of returns" as you call it, for publicly traded companies.  Simply go to sec.gov, follow the links through EDGAR and search for the company by name.  Then look for their 10-Q filing.  Sometimes you may have to look at the parent company.

Here's UnitedHealth Groups (parent company of United Healthcare, among others):

http://www.sec.gov/Archives/edgar/data/731766/000119312505160946/d10q.htm

Or you could go to their website and find the section for investors and look at the latest earnings report.

UnitedHealth Group for example, took in just shy of 20 billion in premiums and paid out about 16 billion in medical expenses in the first six months of this year.  I'd say that's a tidy little profit for one of the worst payers around.

If you're interested here's some other national insurance companies to check up on:

Cigna Healthcare (Connecticut General Life Insurance)

Anthem

Blue Cross Blue Shield

Coventry

PacifiCare (now owned by United)

Now, while your digesting that, consider this.  In 1997 Congress passed and Clinton signed into law the Balanced Budget Act.  This little dandy contains a provision called the "Sustainable Growth Rate" that will cut Medicare reimbursements to physicians by almost 30% over the next five years (average 5% per year until 2014).  So, big deal, doctors get to do some charity work as part of their "social responsibility", right? Sure, until you realize that most major insurance companies (United Healthcare included) tie their reimbursement rates to Medicare's.  That's right folks, you're going to pay higher and higher premiums but your doctor will get less and less money.

So where's it all going?

took in just shy of 20 billion in premiums and paid out about 16 billion in medical expenses in the first six months of this year.  I'd say that's a tidy little profit for one of the worst payers around

This is great. We have one expert after another in here. This one thinks that premiums minus payouts equals profit. In this company, the premiums collect themselves and the payouts pay themselves. No employees required. That's terrific. Not only that, but that's supposed to be a 'rate of return.'

Here's news: UnitedHealth's return on assets is about 12%... a little less than Wal-Mart's; not good, not bad, ho hum. Cigna's sucks; you'd do better to have your assets in a passbook savings account. These are not especially profitable companies.

legal immigrants throughout our history have taken care of themselves whether through jobs or community organizations or ethnically focused religious charities or other means, primarily because they don't have to hide.

Seems to me that giving people even the theoretical ability to get health-coverage providing jobs is superior to not doing so, especially when combined with all of the other benefits of increased legal immigration.

Either way, I must take strong exception to your conflating illegal immigration with legal immigration -- that is factually wrong, morally questionable, and political suicide for Republicans.  We should oppose illegal immigration, even if we differ on how, but if you start to go down some nativist path to opposing legal immigration, you will alienate vast parts of the population.

-TS

I would also say that legal immigration has been a great help to our country, particularly in the area of science, engineering and high tech.  Talented people come here from all over the world.  And sadly, we are not producing our own engineers and scientists as well as we should, so cutting off that inflow of brain power could have dire consequences in the long run.

Dr. Bartlett is quite accurate with that summary.  

Having spent 10+ years working on the other side of the hospital doors in an ambulance, I see many of these problems, albeit from a slightly different perspective.

The thing that is often lost in this discussion is the chain reaction it initiates in the entire healthcare system.  More sick people admitted to the hospital results in longer waits in the ER.  Longer waits in the ER mean that the ambulance often has to wait with their patient until an open gurney can be found.  That continues to the next person to call 9-1-1.  

It's a nasty cycle.

It continues... the EMTALA act mentioned by Dr. Bartlett covers "emergency" care: Heart attacks, asthma, car wrecks, and the like.  It doesn't apply to preventative care or routine care (say, dialysis for a patient with kidney disease.)  Ergo, the dialysis patient doesn't get the care they need, and ends up in the ER with critical levels of toxins in his system.  That results in an admission to the hospital ICU, a $50,000 hospital bill (that the taxpayer has to pay,) and it all starts over again three weeks laer.

I don't want to return to pre-EMTALA days, but EMTALA is destroying the healthcare system from the inside.  

Sorry to be so long winded... I'm a bit passionate about this issue.  

Tort reform is hard because you're fighting wealthy and very saavy trial lawyers who are willing to fight.  In a sense, illegal immigrants are easier to pick on because they're not as capable of fighting back as the trial lawyers - even thoughthe trial lawyers are doing lots more damage, in my opinion.

2002 is the bottom year. The percentages are simply net profit/total revenues, straight from the companies' annual reports.

The trouble with the published rates of return is that I don't KNOW of any companies that are both publicly traded, and only sell health insurance. Getting the rate of return for, say, Cigna, as a whole, doesn't help much, because the health insurance numbers are mixed in with the eighteeen jillion other kinds of insurance that people sell. With a lot more digging, it's likely possible to get information on just health insurance... but I have payroll to run, code to write, and kids to get dressed and out the door.

Yeah, the problem with our health care system is that up to this point everything in our economy is getting more and more efficient except health care(and symphony orchestras).  Things that do not get more efficient get marginally more expensive over time (one reason symphonies now need massive support above and beyond tickets, and why the big band era died).  Solutions for how to pay for health care need to be made, but ways of making it more efficient would also be greatly appreciated.

I know Newt Gingrich is working very hard on this as well as people on the left from the Clinton administration.  Does anyone else feel that the intellectual quality of Gingrich and Clinton are sorely missed?  Sure neither of them are moral giants, but does anyone believe the pathfinder to new solutions for our country is going to be Roy Blunt?  I don't know, just a thought.

Oh, my, yes. You've put your finger on the worst part of it: if you aren't having an emergency, you aren't covered by EMTALA. There's no requirement that prenatal care be provided, so the (mandated) ED delivery is complicated and the baby is more likely to be ill. The emergent heart attack is treated, but the beta blockers that would prevent the worst of the post-MI complications aren't necessarily available, and there's no provision for prior care that might prevent the heart attack in the first place.

None of which is a problem with EMTALA, and none of which justifies another law like it for primary care. EMTALA only keeps people from dying at the door of the emergency department. It doesn't guarantee access to health care, and it would be utterly catastrophic for it to be construed in that fashion. Health care is in trouble right now, but driving a stake through its heart isn't the prescription I'd recommend.

use the emergency room for non-urgent care anyway and this law does seem to force the hospitals to treat them whether they can pay or not. This is why emergency rooms are so jammed up with patients.

One solution would be a series of low-cost clinics for people without insurance, similar to the health care clinics that universities provide for their students. This would drain off a lot of the people who go to the emergency room for everything and anything.

Didn't we both just post in a thread discussing the absolute unwillingness of our authorities to enforce our immigration laws?  We have illegals picketing, we have illegals being provided taxpayer-funded day-laborer pickup points, we have illegals getting scholarships and drivers licenses... Hiding from what and from whom?  Nasty nativists like me?  

Seems to me that giving people even the theoretical ability to get health-coverage providing jobs is superior to not doing so, especially when combined with all of the other benefits of increased legal immigration.

Earners of low wages don't get health insurance.  The guy picking strawberries in the Central Valley isn't going to get health insurance just because he has a green card now.  He can't afford it at $5.15 per hour, and his services aren't worth that much to his employer.  If we force his employer to provide health coverage, we're back to raising prices of all the things you like to remind us that mass immigration keeps cheap.  More likely, though, in the absence of aggressive enforcement against employers, they'll just find illegals to work below the new prevailing wage.  The would-be immigrant who could command a wage likely to be accompanied by health insurance, will likely come here legally.

Either way, I must take strong exception to your conflating illegal immigration with legal immigration

Why not address the point that an increase in supply usually leads to a decrease in price?

health insurance from somewhere, we pay for the cost of his medical care anyway in the cost of higher insurance premiums, which is a ridiculously ineffecient way to suppy health care to the working poor, especially when they utilize emergency rooms as their primary care option.  Better that we pay more for our fruits and vegetables than pay for the healthcare of the farmworkers the way we are now.

Or better yet, break the link between employers and health insurance completely like most of the rest of the industrialized world does.

Medicaid is actually a surprisingly efficient system.  Ezra Klein crunches the numbers:

A couple years back, the Kaiser Commission on Medicaid and the Uninsured collated some data gathered by Jack Hadley and John Holahan to compare Medicaid with private insurers. The results were clear: Defunded though it may be, Medicaid is far cheaper than the private market. When you control for the health of the patient (and Medicaid, for a variety of reasons, has many more ill and disabled low-income users than does the private market) and compare the per-capita expenditures on patients under private insurance and Medicaid, our big government bureaucracy spends $501 less a year on the average adults than does the magic-o'-the-market runner-up, a savings of 22 percent. Treatment of children is the same way, costing $349 less (32 percent) under Medicaid.

And is this just lower utilization of services? Do private insurers cost more because they do more? No: Among adults, there's no difference in services received; among children, Medicaid beneficiaries actually seek more care despite the 32-percent savings. Not a bad deal.

The worries about Medicaid as a wasteful entitlement arise, I think because people see it eating up more and more of the budget and conclude that this is unsustainable.  They're right that it's unsustainable, but the unsustainability is entirely a result of how health care costs are rising.  Put in some kind of solution to health care costs -- most likely, by finding some way to reduce the gargantuan health insurance bureaucracy that forces doctors to spend big money processing insurance company paperwork -- and Medicaid will be under control.  

An excellent post, Nick.  This is one of several important problems that arise from how medical care is organized here.  It's also one of several areas where public services are stressed by the more or less unrestricted flow of immigrants to the country.

What's your suggestion for a solution?

But if the worker doesn't get health insurance from somewhere, we pay for the cost of his medical care anyway in the cost of higher insurance premiums,

Which is exactly what I was trying to get "The Sophist" to acknowledge.  You can't have a welfare state and essentially unrestricted immigration.  You will simply attract, and pay for, the sick and poor of the entire world, bankrupting the system in the process.  You can have one or neither, but you can't afford both.  

which is a ridiculously ineffecient way to suppy health care to the working poor, especially when they utilize emergency rooms as their primary care option.

Probably.  Of course, countries with socialized medicine aren't usually happy with their healthcare, either.  It's probably an iron law:  no one is satisfied with healthcare.

Better that we pay more for our fruits and vegetables than pay for the healthcare of the farmworkers the way we are now.

That's what I keep saying, but it's not something your supposed to say...

is in assuming that I support the welfare state in any way, nevermind socialized medicine.

My point was fairly narrow -- that to blame the woes in our healthcare system, specifically in the emergency rooms, on immigrants, both legal and not is silly.

But the expanded policy preference I have is not to limit immigration, which is an engine of growth, but to eliminate the welfare state, which is not.  I frankly have no real issues with allowing hospitals and physicians to refuse treatment to those who cannot pay.

"Oh, how heartless!  Oh, how disgusting!"  Yeah, yeah; too bad, so sad, life's tough, and no one promised you a rose garden, as we legal immigrants like to say.  Charitable works, such as treating the poor, are the proper province of private social organizations, not the government.

To paraphrase the first poster, better that we not pay for the healthcare of the farmworkers the way we do now, and see what happens to the price of fruits of vegetables.  Flaws with our healtcare system run deep, I'm afraid, starting with our legal system, going into the insurance system, and involving things like how doctors are licensed, pharmaceutical companies regulated, and so on. I'm afraid that even if we reduced ALL immigration to ZERO, we'd still have massive problems in the healthcare system, unless you think the only reason why we have poor people in this country is because of immigrants.

-TS

But the expanded policy preference I have is not to limit immigration, which is an engine of growth, but to eliminate the welfare state, which is not.  I frankly have no real issues with allowing hospitals and physicians to refuse treatment to those who cannot pay.

"Oh, how heartless!  Oh, how disgusting!"  Yeah, yeah; too bad, so sad, life's tough, and no one promised you a rose garden, as we legal immigrants like to say.  Charitable works, such as treating the poor, are the proper province of private social organizations, not the government.

Setting aside the debate about whether or not society should be willing to allow people to die for the lack of some base level of medical treatment, I think we're well served by having a requirement that emergency rooms provide emergency treatment to whoever shows up.

I have health insurance, but there are times when my health insurance card is not with me.  If at one of these times I happen to get hit by a truck (or, if I get knifed by a thief and then he steals my wallet) I don't want the emergency room debating over whether or not I'm actually a good candidate to be fixed up based on whether or not it seems likely I'll pay them back.  Emergency situations are ones were there's not really an opportunity to negotiate, choose another vendor, go obtain additional records, etc.  So, giving the patient the benefit of the doubt here is important.

On the other hand, I agree that it's not fair to force a doctor to treat me with no assurance he is going to get paid as a result.  I'd certainly be in favor of some sort of universal catastrophic health insurance as one way to address the current imbalance.  There may be other approaches as well.

I do agree that immigration is not the root cause of the problem here.

that you like the welfare state.  I was pretty sure, and now see it confirmed, that you don't.  You are realistic enough to concede, though, that we're not going to get rid of it, and that in fact, we're likely to continue to expand it.  

My point was fairly narrow -- that to blame the woes in our healthcare system, specifically in the emergency rooms, on immigrants, both legal and not is silly.

Immigrants do make up a disproportionately large percentage of the uninsured.

"Oh, how heartless!  Oh, how disgusting!"  Yeah, yeah; too bad, so sad, life's tough, and no one promised you a rose garden, as we legal immigrants like to say.  Charitable works, such as treating the poor, are the proper province of private social organizations, not the government.

I have an ambivalent reaction to these sentiments.  I agree with the latter part, but think it's rather too late for that; you can't spend three centuries wiping out intermediate social institutions in favor of economic rationalization and then say that poverty is no business of the state.

Flaws with our healtcare system run deep, I'm afraid, starting with our legal system, going into the insurance system, and involving things like how doctors are licensed, pharmaceutical companies regulated, and so on. I'm afraid that even if we reduced ALL immigration to ZERO, we'd still have massive problems in the healthcare system, unless you think the only reason why we have poor people in this country is because of immigrants.

No, the only reason we have poor people in this country is not because of immigrants.  I'm not sure why you even imply that this is what I think.  Yet it is still a fact that immigration of the poor is a very important reason why we have as many poor people as we do, and there's good reason to believe that allowing the poor of other countries to immigrate hurts poor and working-class people who are already here.  As for the rest of the healthcare system, yes, it has numerous problems.  None of the ones you mentioned bear directly on the presence in our emergency rooms of uninsured patients in the way that a policy of allowing a million new mostly uninsured, mostly unskilled immigrants into the country every year does.  And nevermind the border crossers who go to hospitals in California and Texas rather than risking the hospitals of Nuevo Laredo and Tijuana.  We pay for them, too, even if they never spend a night on American soil.

Re: I frankly have no real issues with allowing hospitals and physicians to refuse treatment to those who cannot pay.

You'd better think that one through for a moment. And if you can't see a huge problemn there, here's a scenario:

You are beaten and robbed in a strange town where no one knows you. Or maybe you suffer a heart attack and your wallet is stolen. In either case you are brought unconscious to the ER. You have no ID, there's no way to determine if you have insurance or so much as a penny in a bank account.

Should you be left to die because the hospital cannot determine if you can pay for treatment? Would you personally be willing to be the person that is left to die on the street?

Or (a somewhat lesser problem): what's to be done with a person who agrees to pay the bill but later can't--if he has no assets and no income then the bill will not be paid. Maybe he even blows it away through bankruptcy. Well, there's never any such thing as an unpaid bill, so those costs will be tacked onto other people's bills regardless.

So one way or another  the only practical solution is to provide a mechanism for health care payment in all such cases. Mind you it does not have to be socialized medicine, there are several market-based plans for universal healthcare out there, and whats' wrong with that?

Meanwhile, immigration as the engine of economic growth? To be polite and obey the rules: what a load of taurine byproduct!

But I'm sure the cheap strawberries more than make up for the inconvenience of non-functional emergency rooms

This can be viewed as an externality, my favorite new vocabulary word.  The cost of the farm worker's health care, whoever you think should be responsible for it, gets dumped in the lap of the doctor.  How much do doctors like strawberries?

People get sick.  If they don't get treated, they often die.  So, they do whatever they can to get treatment.  Lots of times, a regular medical practice won't see them, so they go to the ER.

At this point, we find it morally repugnant to just let poor people die from treatable conditions, so we require hospitals to provide emergency room access whether folks can pay or not.

The cost of this gets pushed around to whoever is holding the short straw for this particular legislative cycle.  As always, ultimately it's you and me, in one form or another.

It happens to be that many poor people are illegal immigrants.  The flood of illegal immigration makes this specific problem more acute, but doesn't actually cause it.

The cause is that health care in this country is very costly, and it's provided in a relatively ad hoc and unplanned manner.  Folks that work above-entry-level jobs with larger companies get health care at work.  80% of Americans work for "small businesses", however, so that leaves a gap.   Older folks get Medicare.  Poor kids and maybe their moms may also get health care through the state.  

Anybody not in one of those groups scrambles.  Folks that can afford it, buy health care directly.  It ain't cheap.  Folks that can't do without.  I know a number of them, and it's no fun picking between, for instance, being able to pay your bills and getting necessary surgery.

You may say that the solution is to just make everyone responsible for paying their own way, but the result of that will be that folks with less money and more problems will, basically, die from preventable conditions.  Is that where we want to go?

I know what the various blue state solutions look like.  What's the red state solution?