Obamacare? what are your thoughts

Delicate Flower · Apr 25, 2014

Insurance, as a general concept, is meant to cover you when costs would otherwise be catastrophic (on some level or another). Think about car insurance. You don't run and make a claim when you get one scratch on your car. You don't expect insurance to cover oil changes or new tires. But if you have an accident, it is there to cover that high expense. You pay premiums even when you don't use it, but the premiums and deductible are set to a level which is appropriate for the coverage you want. Costs are kept low because insurance companies compete with each other for your business. Althought certain insurance companies have arrangements with certain garages and mechanics, by and large you shop around to choose the best price/service/whatever suits you for both preventative care (maintenance) and acute care (repairs). And the law requires all drivers to have insurance.

Health insurance has become more like health prepayment cost sharing arrangements where people want and expect their insurance to cover at least part of even small claims, like a visit to a doctor for a sore throat, or an antibiotic prescription. The ACA does not allow Catastrophic coverage except for young people (not sure of the age, but I'm past it). Many people have no idea how much even basic health care costs, because they just hand over an insurance card and only worry about the copays. There is little to no shopping around (at least on price factors) for providers because as long as you are in the network, there is no difference in cost to you. Here in NC, there are only 2 health insurance companies on the ACA marketplace. Not much competition there.

I have read up on some of Dr. Ben Carson's ideas, and some of it makes sense, like giving every American money into an HSA that they can spend as they see fit. Encourages competition and shopping around for price, which would seem to bring costs down.

I think the disconnect between the consumer and paying for actual costs of care is a big part of what has allowed costs to skyrocket. Maybe at least some hospitals could compete in low cost markets, where people want good healthcare without all the extra amenities and fluff. Like the Motel 6 vs. the Hilton. The rich people wouldn't necessarily get better care, just more comfort and convenience. That's pretty much the same way it works with everything else, it seems to me. Or have a Coach and First Class section, LOL.

Not_A_Hat_Person, RN · Apr 25, 2014

But health care isn't like choosing a hotel or a car insurer. If car insurers routinely refused to pay claims for catastrophic losses because the car had a flat tire once, who would defend that (aside from auto insurers)?

Delicate Flower · Apr 25, 2014

Sure, I never said they should not be regulated. I think the fact that pre-existing conditions are covered is one of the best features of Obamacare. I just think there should be a way to put the purchasing decisions back in the hands of consumers, at least partially. I think basic (inexpensive care) is a good place to start. I am not talking about (true) emergency care. People should know how much something is going to cost before they buy it. They can shop around, and make the best decision for them. If they are rich and want the most cushy option, they can pay for it. If they are poor and can't afford any option, it will be provided for them (medicaid). If they are middle class and want to shop around for the most affordable option to use their limited funds on, they can do that too.

calivianya, BSN, RN · Apr 25, 2014

Sure, I never said they should not be regulated. I think the fact that pre-existing conditions are covered is one of the best features of Obamacare. I just think there should be a way to put the purchasing decisions back in the hands of consumers, at least partially. I think basic (inexpensive care) is a good place to start. I am not talking about (true) emergency care. People should know how much something is going to cost before they buy it. They can shop around, and make the best decision for them. If they are rich and want the most cushy option, they can pay for it. If they are poor and can't afford any option, it will be provided for them (medicaid). If they are middle class and want to shop around for the most affordable option to use their limited funds on, they can do that too.

I think this is an excellent idea, and I just have to say that I would RUN, not walk, to work at a "basics" hospital where the expectation was that I take care of my patients' needs, not that I provide every single family member with free coffee and engage them in conversation for an hour about their dogs. It would be nice.

MunoRN, RN · Apr 25, 2014

I think this is an excellent idea, and I just have to say that I would RUN, not walk, to work at a "basics" hospital where the expectation was that I take care of my patients' needs, not that I provide every single family member with free coffee and engage them in conversation for an hour about their dogs. It would be nice.

There are hospitals that exist outside of the competitive environment that you're referring to; VA hospitals. In general I don't think the idea of changing all hospitals to government run are all that popular, even among more "socialist" liberals. Regulated service prices on the other hand would at least remove the inflation effect that amenity based competition can cause.

MunoRN, RN · Apr 25, 2014

Insurance, as a general concept, is meant to cover you when costs would otherwise be catastrophic (on some level or another). Think about car insurance. You don't run and make a claim when you get one scratch on your car. You don't expect insurance to cover oil changes or new tires. But if you have an accident, it is there to cover that high expense. You pay premiums even when you don't use it, but the premiums and deductible are set to a level which is appropriate for the coverage you want. Costs are kept low because insurance companies compete with each other for your business. Althought certain insurance companies have arrangements with certain garages and mechanics, by and large you shop around to choose the best price/service/whatever suits you for both preventative care (maintenance) and acute care (repairs). And the law requires all drivers to have insurance.
Health insurance has become more like health prepayment cost sharing arrangements where people want and expect their insurance to cover at least part of even small claims, like a visit to a doctor for a sore throat, or an antibiotic prescription. The ACA does not allow Catastrophic coverage except for young people (not sure of the age, but I'm past it). Many people have no idea how much even basic health care costs, because they just hand over an insurance card and only worry about the copays. There is little to no shopping around (at least on price factors) for providers because as long as you are in the network, there is no difference in cost to you. Here in NC, there are only 2 health insurance companies on the ACA marketplace. Not much competition there.
I have read up on some of Dr. Ben Carson's ideas, and some of it makes sense, like giving every American money into an HSA that they can spend as they see fit. Encourages competition and shopping around for price, which would seem to bring costs down.
I think the disconnect between the consumer and paying for actual costs of care is a big part of what has allowed costs to skyrocket. Maybe at least some hospitals could compete in low cost markets, where people want good healthcare without all the extra amenities and fluff. Like the Motel 6 vs. the Hilton. The rich people wouldn't necessarily get better care, just more comfort and convenience. That's pretty much the same way it works with everything else, it seems to me. Or have a Coach and First Class section, LOL.

The car comparison is actually valid but I think you're applying it wrong. In health insurance the insurance "system" is ultimately responsible for all "maintenance and resulting damage" costs everyone incurs. It's sort of like when you lease a car, the dealer leasing the car will eventually incur all costs related to how well the car was taken care of, which is why they require you take care of it. In order to make sure this happens, they will often charge you for all of the required maintenance up front making it more likely you'll actually get it done.

You've complained about the high deductibles of insurance, but also complained that people should pay an amount they can afford on their own healthcare and insurance should just be for costs beyond that, which is what the deductible insurance plan is. The premiums are only for the costs above what people can typically afford themselves in a typical year as well as for preventive care to keep those costs as low as possible.

Not_A_Hat_Person, RN · Apr 25, 2014

I think the disconnect between the consumer and paying for actual costs of care is a big part of what has allowed costs to skyrocket. Maybe at least some hospitals could compete in low cost markets, where people want good healthcare without all the extra amenities and fluff. Like the Motel 6 vs. the Hilton. The rich people wouldn't necessarily get better care, just more comfort and convenience. That's pretty much the same way it works with everything else, it seems to me. Or have a Coach and First Class section, LOL.

Comparison shopping for health care providers is a good idea in theory, but it just doesn't work in practice. Among other reasons, providers are very reluctant to quote prices, even to people who plan to pay out of pocket. I've only seen firm prices posted at retail flu clinics and urgent care clinics, which (in my area) don't take Medicare or Medicaid.

LACONIA, N.H. — Seven months pregnant, at a time when most expectant couples are stockpiling diapers and choosing car seats, Renée Martin was struggling with bigger purchases.
At a prenatal class in March, she was told about epidural anesthesia and was given the option of using a birthing tub during labor. To each offer, she had one gnawing question: “How much is that going to cost?”
Though Ms. Martin, 31, and her husband, Mark Willett, are both professionals with health insurance, her current policy does not cover maternity care. So the couple had to approach the nine months that led to the birth of their daughter in May like an extended shopping trip though the American health care bazaar, sorting through an array of maternity services that most often have no clear price and — with no insurer to haggle on their behalf — trying to negotiate discounts from hospitals and doctors.
When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. “It was unreal,” Ms. Martin said. “I was like, How could you not know this? You’re a hospital.”
Midway through her pregnancy, she fought for a deep discount on a $935 bill for an ultrasound, arguing that she had already paid a radiologist $256 to read the scan, which took only 20 minutes of a technician’s time using a machine that had been bought years ago. She ended up paying $655. “I feel like I’m in a used-car lot,” said Ms. Martin, a former art gallery manager who is starting graduate school in the fall.

MunoRN, RN · Apr 25, 2014

With a few exceptions, individuals don't get a better deal on healthcare services than insurance companies do, in fact they pay ridiculously higher prices. In theory it sounds great, in practice the ability to get in on the insurance company's lower negotiated prices is a big reason why people get insurance.

http://livingwithmcl.com/BitterPill.pdf

DoGoodThenGo · Apr 25, 2014

Cannot speak for everywhere but at least here in in NYS/NYC full service hospitals are increasingly seen as loss leaders and aren't attracting the same sort of interest including financing as before. Most recent example of this came in the form of bidding for Long Island College Hospital in Brooklyn. Only because the process was rigged to prefer a full service hospital over other uses did the winning bidder succeed, and even then the jury is still out as to how things will shake out, one thing is certain a vast full service hospital appears to be on shaky ground.

You saw this with Saint Vincent's in the Village as well. Years ago a prime hospital site in a very upscale and growing increasingly wealthy part of Manhattan would have been a no brainer. Someone or group would have put together financing to deal with the nearly 1bil USD debt and *saved* that hospital. But not only did the major healthcare players here pass, so did anyone else besides the real estate interests (the Rudin family in particular) who wanted the land, but not the hospital.

Debating hospital rates works well when there is competition with all things being equal. As many of us know that is just not always possible with hospital or even healthcare.

Am all for reading the labels before buying as the next person, but just because some hospital in Podunk NJ, costs $$ for open heart surgery while NYP in Manhattan, NY(where Bill Clinton went IIRC) costs $$$$ does not mean I'm going to high-tail it down to New Jersey just to save a few pennies. I want to see information such as outcomes, infection rates, medical/nursing errors, long story short what is the quality of care.

toomuchbaloney · Apr 25, 2014

I think that the only people who can shop health services based upon outcomes and not upon cost are the well insured and the wealthy. Everyone else gets what they can afford where they can afford it. In the states which have not expanded Medicaid that means that hundreds of thousands are still just window shoppers.

CassandraWilliams · Apr 25, 2014

It's another tax on the middle class. The Obamacare was a conservative right-wing agenda.

SycamoreGuy · Apr 25, 2014

It's another tax on the middle class. The Obamacare was a conservative right-wing agenda.

For something that was a "conservative right-wing agenda" the Dems fought pretty hard to make and keep it the law of the land. Heck, they passed it without a single republican vote! Too bad conservative can't get any of their other ideas passed without even voting for them.