But What If He's Irrational Because He's Sick?

Perhaps you have seen the video of the outspoken candidate for US President who raised the issue of someone who has made the decision not to buy health insurance and then, at age 30, becomes sick and will die without medical care.  And perhaps you heard his audience response? See Krugman link.

People make economic decisions which affect health care for a variety of reasons, including their inability to pay for what they need. But one of the reasons that people make "bad" decisions is their own health.  Cancer may be associated with severe depression which makes a person incapable of making a rational decision on every day things, such as purchasing health insurance. Brain trauma, brain tumors, brain infections, diabetes, Alzheimer's disease and other dementias, metabolic disorders such as Wilson's disease - all may be associated with inappropriate decision making.

The solution - in America -  is not to throw these people (or their family members, including their children) onto the junk pile for easy disposal.  It is finding the compassion and common sense to treat them humanely and appropriately. It is surprising for someone from a medical family to miss this obvious point.  What else is he missing - and is there some medical reason for his missing it?

NO HEALTH INSURANCE? - YOU ARE NOT ALONE.

HOW MANY AMERICANS DON'T HAVE HEALTH INSURANCE?
Read this and check the link to find out!

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–September 2010


Highlights
 From January through September 2010, 49.5 million persons of all ages (16.3%) were uninsured at the time of interview, 60.8 million (20.0%) had been uninsured for at least part of the year prior to interview, and 36.1 million (11.9%) had been uninsured for more than a year at the time of interview.
From January through September 2010, the percentage of children under age 18 years who were uninsured at the time of interview was 8.2%.
Private coverage decreased among near poor adults aged 18–64 years, from 52.6% in 1997 to 34.6% in the first 9 months of 2010.  The uninsured rate (43.9%) is higher than the private coverage rate (34.6%) for this population.
From January through September 2010, 59.1% of unemployed adults aged 18–64 years and 23.5% of employed adults in this age group had been uninsured for at least part of the past year. Also, 36.4% of unemployed adults aged 18–64 and 15.0% of employed adults in this age group had been uninsured for more than a year.
During the first 9 months of 2010, 24.9% of persons under age 65 years with private health insurance at the time of interview were enrolled in a high deductible health plan (HDHP), including 7.4% who were enrolled in a consumer-directed health plan (CDHP). Almost 50% of persons with a private plan obtained by means other than through employment were enrolled in a HDHP. An estimated 20.0% of persons with private health insurance were in a family with a flexible spending account (FSA) for medical expenses.

US Income, Poverty and Health: FindThe Facts Yourself

If you prefer facts to rhetoric:

The world's industrial development, wealth and health: where do we stand? A brief informative video illustrates changes over the last 200 years.
http://www.youtube.com/watch?v=jbkSRLYSojo

http://www.cdc.gov/nchs/

http://www.nih.gov/

http://www.macfound.org/atf/cf/{B0386CE3-8B29-4162-8098-E466FB856794}/HCD_NET_Status_Health.pdf

http://www.census.gov/prod/2006pubs/p60-231.pdf

For more, Google "US income poverty and health".   Read, think and then communicate with your Congressperson who needs input from constituents rather than more campaign support from lobbyists.

Texas Health Insurance Maternity Benefit Unavailability - Response to Comment

I don't know whether the commenter is correct that passage of the Affordable Care Act was responsible for strategic actions taken by Texas health insurers to raise rates or make unavailable maternity benefits (2 sides of the same coin). Was the decision by insurers to raise their rates for individuals seeking maternity benefits as part of their insurance package solely due to health care reform or was it a response to actuarial experience (increases in the range of 10-15% have not been unusual in the health insurance business in many states, even before health reform),  to the extraordinarily high costs of  Texas health care (as documented in 2010 journal articles and federal government discussions),  was it a business strategy to mobilize public opinion against health reform, or was it a non-publicized highly selective business or political strategy?

I don't know.  Do any of my readers have other insights?

What About My Child Who Was Cured of Cancer?

For several days, radio and televisions broadcasts have said it: beginning September 23, 2010, under the Affordable Care Act applying to grandfathered group health plans, health insurance enrollees who are younger than 19 years of age cannot be excluded from benefits or denied coverage because a condition was present before the date coverage became effective (or denied).

The hype sounds good, but what if your 19-26 year old child was treated for heart disease, lung disease, cancer, leukemia, Hodgkin Disease, Wilson's Disease or any other serious condition and the insurance company says "no" to someone age 19-26 with a pre-existing condition under the grandfathered plan?  (A grandfathered plan was one existing on March 23, 2010 and a new plan is one established after that date.) While minors must be covered, not until 2014 will the  pre-existing prohibition for adult children be eliminated.

Sophisticated advisers stress the importance of keeping a close eye on employers' grandfathered plans.  When new insurance is written or major revisions to existing plans take place,  "grandfathered" plans may become new plans and work under a whole new set of more consumer- protective rules.  Pay attention.

If Ronald Reagan's Health Coverage Was Cancelled

The story was told to me in the mid-90s with great enthusiasm, by a former executive of a major California-based health insurance company. It seems that a major California health insurer, which had enrolled State of California employees for many years, did a study to find out why writing health insurance for this group was becoming less profitable, and learned that it was experiencing adverse selection: all of the State of California employees who had selected the program were over age 40; the younger employees joined Kaiser which had much lower premiums.

So the insurer did just what insurers still do to employers. It notified California that it was no longer interested in the state's business, and that upon the termination of the contract, it would no longer provide coverage for state employees. The insurer "fired" the State of California.

Though I don't remember the name of the man who told me the story, I remember his grin and the twinkle in his eyes, when he related that among those who lost his coverage was then governor, and soon to be President, Ronald Reagan. The person who told the story said that when the insurer discovered its politically disastrous mistake, it withdrew its health insurance termination decision so that, once again, Ronald Reagan was insured.

I had no independent verification of the story. But it strikes me as quite consistent with health insurers' behavior. So I thought I'd pass it on. Perhaps one of my readers can give us additional details.

Insurers Revoke Plans To Avoid Paying For Patients With High Costs

While "shame" is not an insurance concept, after reading the brief article cited below, you may conclude that "shameless" may be an insurance industry concept.

The last paragraph of a news release by Kaiser (click title above to get linked-in):

"The committee's investigators found 19,776 rescissions from three large insurers over five years, which led to savings of $300 million. "Several lawmakers at the hearing suggested there were things the companies could do right now: They could vet applications when they receive them, rather than waiting until people get sick; they could consider whether something that was omitted was related to a current health condition before rescinding; and they could be more careful to positively identify fraud before rescinding a policy" (Silberner, 6/22"

Read Paul Krugman's "Keeping Them Honest."

My rule is not to waste words. Just read "Keeping Them Honest" in The New York Times, Friday June 5, 2009, p. A21. Krugman's short message is: "1) Don't Trust the insurance industry" and " 2) Don't trust the insurance industry.

To which I can only add, as a physician and as a former active attorney who negotiated with insurers and had to deal with their failures to deliver what was promised, Krugman is right.

Problems Ahead For Concierge Medicine?

Concierge practices may be structured differently, but the fundamental illusion conveyed is that the patient will get special, convenient, extra, perhaps even better care, than the person who sees his or her "ordinary" physician. At one of my Thursday physician lunches, a specialty physician regaled colleagues with the story of a concierge physician who called to demand an immediate appointment for one of his patients. The concierge physician's patient got the next available slot for a consultation, just as any other patient would have.

On January 20, 2009. the Maryland Insurance Commissioner announced a report that some of the concierge arrangements cross the line of providing insurance and suggested that physicians seeking a concierge practice seek "appropriate professional and legal advice in this area." The Maryland Insurance Administration raised caution flags with respect to two types of arrangements, the "Annual Evaluation Model and Bundled Fee-For-Service Models." It did not elaborate on balance billing and medical ethical issues in the context of these practices.

Before signing up as a patient in a concierge practice, patients should consider whether they should forgo being treated by a busy energetic experienced "ordinary" physician whose practice generates sufficient income independent of practice gimmicks.

The Value of A Medical Service - II

John was a pleasant man with late stage polycythemia rubra vera, a chronic disease in which the body makes excessive blood: too many platelets, red cells and white cells. Eventually, his bone marrow failed as it was replaced by fibrous tissue. Other organs made his blood cells.

I had followed John, a retired engineer, for years. In addition to the usual medical issues, we talked about his family, his church work, his computer programming and other activities. Gradually, John's blood counts worsened, he stopped eating normal meals because he filled-up too quickly, and his spleen sat in his abdomen like two professional-sized footballs, lying side to side. John needed to have that enormous spleen removed.

It took more than two weeks to find the right doctors: a general surgeon to perform the high-risk operation, a vascular surgeon who specialized in capturing lost blood so that it could be given back to the patient, and other members of the support team. Finally, John came to the brightly lit and crowded operating room where his surgery began. His huge spleen was glued to his left diaphragm (the muscle which moves air in and out of the lungs). Surgery was difficult and bloody. The team spent five hectic hours dissecting and removing the spleen, dealing with John's massive bleeding, capturing and recycling John's blood, transfusing John with blood components from the Red Cross, and dealing with John's unstable vital signs.

Finally, the surgery was over and John was in the recovery room. I left the operating room to tell John's family and friends how he had done, indicating that their prayers may have played a role in his positive results.

Two weeks later, John was in my office. His enormous abdominal mass was gone. He was eating again. His blood counts were dramatically improved. A month after his surgery John was feeling better than he had in months. That's when he told me that, because he found that he could buy health insurance for five dollars less per month, he was moving to a different plan and wouldn't be seeing me any more.