(I presume it is a possibility that in the USA one can lose their medical coverage through the insurance company if they make too many claims, is this correct? It’s what I have heard and read

Health insurance in the United States is regulated.  Typically, the employer purchases the health insurance plan at a group rate.  The employer picks up most of the tab and the employee pays the remainder.  While the coverage is in effect, you may not be dropped for too many claims under the policy.  When the group plan comes up for renewal, what is likely is that there will be premium increase if there were a substantial number of claims that required extensive medical care.  The stickier issues center on whether a condition is a pre-existing condition under the terms of the policy, and whether the course of treatment sought is necessary.

Regarding the denial of claims, one does have options should they choose to exercise them.  The recourse one has is different depending on how the policy was purchased.  If an individual purchased the policy themselves (not through their employer, but as an individual plan) they may sue the insurer directly for a denial of coverage.  If the individual receives insurance through an employer plan, then federal law (ERISA) governs.  ERISA requires that there must be an appeals process if a dispute arises regarding the necessity of treatment.  If the individual still remains unsatisfied after exhausting the administrative remedies, suit may be brought.  Damages under ERISA are not as extensive as may be had by the individual who purchased the insurance policy.

I hope this helps to clarify the matter for you.

Gronker,

Your relative’s death is a sad story.  But she made the choice not to go the doctor, mostly as a cost savings measure.  We all have done that I expect.  But it was a choice.

I really think you missed the point of Les’ original post.  It struck me that what Les was arguing, and to which I agree, is that people shouldn’t have to make medical decisions based on financial considerations.  You should decide whether you want to go to the doctor or not based on how you feel versus on how much you can afford.  Cost shouldn’t be a limiting factor for receiving care when you need it.  Besides considering the cost of even relatively minor procedures, such as an appendectomy cam cost upwards to $9000, I don’t think giving up your cell phone, rims and cable TV really would make that big of a difference (when those things added up might cost you $500-700 in a year, unless your suggesting that people should save up huge medical care nest-eggs in case they ever really get sick).  As for private medical insurance, in most cases if you don’t get the discounted group rates it is fairly expensive, and the treatments available are limited.  These are all non-concerns when it comes to a public system.  Anything that there are facilities for can be done for anyone.  For example, if I get a rare form of cancer I’m not going to die without treatment because I’ll cost some company too much, if there is a treatment available, I will get that treatment and I don’t have to worry about paying for it.  Public systems are way superior to private system in every measure except wait times (but that’s just a sign that there are a lot of people who are getting medical care in public systems who aren’t getting it in private systems).

Public systems are way superior to private system

This is pretty much not true.  Public systems do cover more people but with inferior care.  The medical profession is no more immune to the free market than any other profession.  The more motivation there is to excel, the more people do in fact excel.  If you paid doctors what you pay teachers, most of the folks that are docs now would be in other professions.

The same (correct) arguments made about drug companies and profits work for healthcare in general.  If there is no financial incentive for innovation and progress, none will happen.  No one will invest in the companies doing the work.  Few, if any, of the great minds needed to do the work will choose to work in the industries.  Great minds will always gravitate to where the rewards are.

There is a reason that a vast majority of the new drugs and medical procedures are produced here, in this country.  There is a reason that none of the wealthy in countries with socialized healthcare use their public systems.  They use private healthcare in their countries or, more often, come to the USA.

Interestingly, I think we have become victims of our success in many ways.  90% of the healthcare provided uses about 10% resources.  It’s that AMAZING 10% that costs so incredibly much.  Ailments that we could do nothing for 20 years ago, we can treat with some success, albeit very expensively.  And it is those costs that insurance companies are forced to spread across all their insured customers. 

We spend $100,000 a day to keep a 4 month premature baby alive with a slight chance of survival.  We all foot the bill for these heroic efforts in higher insurance rates, higher taxes, and higher hospital costs when the hospital has to recoup the loss from non-payment for these services.  No one is willing to cull this kind of thing from the general insurance pool, so we all pay.

If insurance companies were allowed to only cover the 90% majority of procedures, you would see affordable healthcare, even to those not covered in large group policies.  People could then cover that other 10% with a different high risk policy or self insure to some extent.

At some point in the near future, we will easily be able spend 100% of our GDP on healthcare.  As we live longer and we get more and more esoteric procedures to try to extend life longer and longer, this problem will only get worse.  I guess it’s a good problem to have, but its going to take a realistic approach at some point.

And the idea of this decision in the hands of Government makes my skin crawl.

I spent 12 years in the military (with no health coverage concerns) and the last 3 making enough money that coverage has never been an issue. As a young, single, healthy male insurance rates were fairly low. Now, my wife is in the military and I once again have ‘free’ coverage. Because of this, I’ve been slow to awaken to the extent of the problem.

Over the last two years or so, friends of mine in the medical profession and members of my immediate family have begun to grow increasingly frustrated with health care and the ever-rising cost of insurance. I THINK that this would probably be the largest issue (especially in election years) if we weren’t caught up in the endless “War on terror.”

The problem certainly isn’t funds...we already commit more money per capita than any other country to the problem. I’m just not sure how that spending needs to be adjusted to achieve better results.

How much of the spiraling costs are a result of unhealthy lifestyles and the American desire for a “silver bullet solution?” In other words, “Give me a drug so I lose weight” rather than, “How can I lead a healthier life?”

I don’t think the solution is as simple as nationalizing health care. It goes too strongly against the grain of Americans and my experience with the military system has left me with serious doubts regarding the efficiencies of such a system.

I also don’t think there is a single solution that will fit the entire country easily enough. Instead, I think states need more power to develop programs tailored to fit their populations. This would also allow states to learn from each other. The drawback to this idea is that the conservative notion of “lower taxes at all costs” prevents states from raising taxes enough to implement such programs.

Don’t get me wrong, I don’t think higher taxes in general really accomplish all that much...but at SOME level, government has to collect revenues and provide the sinews of society. If we have decided, as a nation, not to do that at the federal level, then we need to start seeking lower level solutions (state, county, city...).

Gronker said: “Public systems do cover more people but with inferior care.”

This is not borne out by health statistics or by my experience.  Millions of Americans get inferior care while a few get care that is assumed to be the standard.  Not only do we spend more per capita on helath care than any other nation, but we spend it on a much narrower band of the citizenry and get less (in aggregate) for it.

Someone mentioned appealing denial of coverage.  Ever try suing an insurance company?  Good luck, low-wage exhausted sick single mom with kids.

Prickley Pear and Socialist Swine got it right.

Ever try suing an insurance company?

Yes, quite a few times.

Your relative’s death is a sad story.  But she made the choice not to go the doctor, mostly as a cost savings measure.  We all have done that I expect.  But it was a choice.  There are programs, both at healthcare providers and State/Local governments, to take care of these costs.  Maybe she might have had to forgo other wants/needs to pay for a doctor visit, but in hindsight, its a lot better than getting dead.

Tell me, Gronker, do you have insurance coverage?  Or is having your head up your ass considered a “pre-existing condition”?

Les’s relative did NOT have a choice.  When you are that sick with pneumonia that it’s capable of killing you, you are in terrible pain, can barely breathe, and can barely move.  If she could have afforded to go to a doctor without spending hundreds or thousands of dollars for treatment, x-rays, hospitalization, and medication, she would have.  It’s not like she had a fucking hangnail.

Do you have any clue how much insurance premiums cost when you don’t have an employer to pay for them?  Do you know how often people get denied coverage even if they can afford hundreds of dollars a month for insurance? 

I’ll give you a clue for free:  cable TV PLUS rims PLUS whatever you consider to be “discretionary items” are STILL a hell of a lot cheaper than insurance premiums, especially if you don’t expect to be sick.  If you’re making a survivable income but not much above that, insurance is the last thing you’ll pay for (renter’s, health, life, auto) because it’s either pay for something you might never need or pay for other things you could really use NOW.  When you can’t afford both, you tend to pay for what you’re going to get the most use out of.

My cousin’s husband works as a hairdresser.  He never paid for health insurance because he wasn’t overweight and didn’t have any chronic health problems, and he didn’t have the financial luxury of paying hundreds of dollars a month just in case he got a head cold sometime. 

He had a massive heart attack late last year out of the blue.  You see, most people think that thin = low risk, and that’s not the case.  As a result of this miscalculation, he and his wife are now up to their ears in debt.  He wouldn’t have qualified for Medicaid, but he couldn’t afford treatment either.  This is where the middle class ends up:  squeezed between unaffordable alternatives.

People who are well off can afford to insure themselves against any and all possibilities, both literally and figuratively.  They can save more money, can afford to invest (and ride out the occasional losses), and can even make one-off expenditures if they really need them. 

Those who are living on the edge are at the mercy of every ill wind that blows their way.  Now, you can whine about having your money “stolen” to help those people, but you should be thanking your lucky stars that you HAVE money to spare.  Money equals choice.  Money equals opportunity.  Don’t ever make the mistake of thinking everyone has the same options that you do.

Consi:

I would encourage you to seek counsel from a Colorado attorney as soon as possible.  Counsel can advise you regarding several possible avenues for recourse that you may have.
ERISA requires that there must be an appeals process if a dispute arises regarding the necessity of treatment.  If the individual still remains unsatisfied after exhausting the administrative remedies, suit may be brought

DOF: Ever try suing an insurance company?
Consi: Yes, quite a few times.

So it would appear that you are a lawyer?
This litigious attitude is not healthy or productive when one is ailing. The stress of having to take on another battle when your primary battle (survival) is at stake serves exactly whom? The insurance company hopes you GO AWAY, the lawyer says “just pay me and I’ll see what I can do”, and, in the meantime, you negotiate with your tumor to stop growing until we can see who will foot the bill....Yowzers, give me the social medicine model.

Appearances can be deceiving.

I’m not advocating litigation.  Only, that there are remedies and recourse already available for those who so choose.

Regards,

DOF: Ever try suing an insurance company?
Consi: Yes, quite a few times.

Annnnnd....?

Did it HELP any?

I’ll refrain from the ‘told you so’ yet. You may have won a couple times for all I know, but I don’t think so.

Even if so - you surely realize that suing takes TIME. A sick person usually can’t simply wait until the matter has cleared up, especially if he/she can’t even be sure of getting redress.

And all this is onyl IF the person has insurance. Try suing the government for not providing help…

No, thanks. Mandatory health insurance for any kind of legal work may be one of the reasons we have such high cost of employment (if thats the correct English term) here in Germany/Europe. But its a sensible thing nonetheless.

I was surprised by some of the reactions to this entry. As a native of sunny old England, I am used to living with a free health service, and have obviously been taking its benefits for granted. We British do a fair amount of moaning and bitching about the NHS (actually, we do a fair amount of moaning and bitching full stop, particularly about the weather), but at least I know that if I’m feeling even a fraction as bad as Les’ relative must have been (so sad, by the way) I can go to the doctor without worrying about the effects on my rather over-stretched pocket. Yes, some of our taxes go towards paying for the NHS - but I’ve always believed that this was part of the ‘sharing’ that our parents told us about as children.

And speaking of children, all those out there that resent the idea of paying a small percentage of your income to fund a free health service - which you would also be entitled to use, by the way - and have justified this by claiming that the recipients are not working hard enough, so don’t deserve your help, what about the families who are having to choose between taking their sick child to the doctors, or putting food on the table next week? Should the child suffer, because their parents are out of work?

I don’t know, I guess it’s just different cultures. It just seems to be all “get get, grab, grab, I worked for this money so it’s mine all mine”. I just think that there’s more to life, and that part of belonging to a society involves contributing to looking after all members of that society. One day you might need that kind of help too.

Gronker,

Public systems do cover more people but with inferior care.

This isn’t the case according to a study published in Medical Affairs (an American medical journal).  In the study (Hussey, et al. (2004) “How Does The Quality Of Care Compare In Five Countries?” Health Affairs 23(1): 89-99.) of the five countries compared (Canada, UK, Australia, New Zealand, US) the United States scored the lowest for quality of care and survival rates in all cases except mycardial infarction, in which Canada did poorest (this was because the treatment modality used in Canadian hospitals was outdated, I think the issue has been since addressed).  Moreover, the United States is the only of the countries to have private medical care.  It seems from the study that in general public or mixed health care systems perform much better than fully private systems.  When medicine isn’t done for profit, there’s less corner cutting, and less attempts to do things as cheaply as possible.  As such quality is higher in public or semi-public systems.

P.S.  The system that had the best results was that of the UK.  The British system, as Missy points out, is a public system like Canada’s.  Canada also did quite well placing third after Australia (which has a mixed system that while offering full public services also allows for private health care providers to take excess load off the public system.  I should also note that the insurance system in Australia is public and, according to the Australian government at least, covers all Australian citizens, though private insurance is allowed as well but not required).

I have written and rewritten my response to you, GeekMom, to try to soften my words and comments.  However, in the end, I decided you didn’t deserve the effort.  You don’t know me but were more than willing to attack me.  That makes you un-pull-punch-worthy.

For the record, I do not have insurance.  As an independent contractor, I have to purchase coverage, not from any group pool.  I pay for catastrophic coverage for my son and wife, but my sleep apnea makes me basically uncoverable.  I have considered taking a safer job just for the medical coverage, but have fought the urge.

My head is not up my ass, I don’t think she had a fucking hangnail, I have plenty of clues, I am not whining about my money being stolen and I don’t make mistakes about other peoples situations—you self-righteous bitch.  Its people like you that make reasoned debate about hard, real-world questions like this damn near impossible. 

Your assumptions about my situation is indicative of the knee-jerk reaction by those on your side of this (and many other) issues.  Just because I personally would benefit from something doesn’t mean I think it’s the right thing to do.  I’m not that shallow or weak.

Les’s relative did NOT have a choice.  When you are that sick with pneumonia that it’s capable of killing you, you are in terrible pain, can barely breathe, and can barely move.
Another assumption – perhaps you are clairvoyant?  I would have hoped that cost would not have kept her from calling the doctor, especially if her symptoms were as you describe.  As her husband, you can be damn sure I would have taken her in myself.  I don’t know Debbie’s situation and I don’t presume to know her.  I don’t feel comfortable using her situation to make my point but I truly hope everyone takes their health seriously enough to go to the doc when they are sick, irregardless of the financial consequences.  Not to do so and then bitch about the consequences is pathetic.

He had a massive heart attack late last year out of the blue.
So your assumption is that he would have not had his heart attack if he had coverage?  He would have gone in and discovered his condition “out of the blue?�?  You are correct that he “miscalculated�? by trying to cut corners with his health care.  Don’t blame the system for it.

He is alive to be in debt.  His miscalculation, health issues and their underlying causes are unfortunate but in the end, he is alive to work off his debt.  As a member of the middle class, I make decisions on the health care for my family.  I have chosen to accept some of the risk myself and if something happens to me, I will take the consequences without blaming anyone but me.

Those who are living on the edge are at the mercy of every ill wind that blows their way.
Guess what?  You will always be on that edge, no matter what your situation.  To think that some government program can change that is naive and childish.  Your attempts to enslave the healthcare system to improve your state-of-mind are sad.

Yes, I feel for the people to whom bad things happen.  Yes, we can do a lot to improve our health system and the access to it.  You and I just differ in how we should accomplish this goal.  That and our approach to the argument.  Do yourself a favor and don’t make assumption about the person you are arguing with – try arguing the facts.

Gronker,

If you’re done with Geekmom perhaps you can try addressing my posts to you.  I have presented arguments for the superiority of public health care versus private for profit health care.  You have yet to say anything about my arguments.

That said I actually have another argument for private systems.  You seemed to suggest that research doesn’t occur in public systems, but that isn’t true.  The newest and most effective protocols for brain, stomach, pancreatic, and breast cancer all come from Canada (in fact they come from the med school here in Calgary).  Moreover, the majority of the work being done on stem cell therapy for Alzheimer’s and Pakinson Disease are being done in Canada and the UK (now this isn’t so much the result of funding issues as much as conservative ideology that doesn’t allow for novel cell lines). 

The most promising treatments for cystic fibrosis are being developed in Canada as well.  See you mistaken assume that private companies do the bulk of medical research, but that isn’t the case.  The majority of research is done in medical schools, and medical schools benefit from the higher public funding of education that is found in such “socialist” countries as Canada, UK, Australia, Sweden, France, Germany and so on.  The US is actually actually losing its lead in medical technology.  With decreased public science and medical funding comes decreased amounts of research.  Moreover, if you consider the debacles involved with the pain killer recalls (all of which were developed by private firms versus public universities) there seems that there is even more reason to think that medical research is best done by not for profit academic institutions.

Errr… you need to drop Sweden from your list according to this article.

Sweden slipping behindOnce among the top countries in medical research, Sweden is worried that it is losing ground | By Karin Nordin
STOCKHOLM—“It’s a gloomy picture,�? said Håkan Billig, secretary general of the Swedish Research Council, when describing the conditions for medical research in Sweden last week. At an international meeting on medical research funding, he was one of several leading lights in the Swedish community who fretted over possible causes for this “slump�? in the country’s position.

Billig believes public funding of medical research in the country stagnated throughout the 1990s. His view was mirrored by Hans Wigzell, former president of the Karolinska Institute and now scientific advisor to the government. Instead of investing the money in medical research, the government is channeling funds to social costs like sick leave and early retirement, he said.

According to Wigzell, the organizational relationship between the government and the research council is contributing to the problem. “We are under the department of education, not the department of health. They don’t love us in the department of health; they think we are expensive,�? he said at the meeting, “International Symposium on Medical Research Funding—Vision for the 21st Century.�?

Cecilia Schelin Siedegård, executive director, Karolinska University Hospital, was also concerned about organization and unclear coordination of health initiatives. In her presentation at the meeting, she pointed to a lack of integration among research, care, and education that should be covered by investing in clinical research in the university hospitals.

In terms of citation index, Sweden has dropped from the second ranked country in the 1980s to the ninth in the 1990s, according to numbers presented by Seidegård. While many speakers found this very worrisome, Thomas Östros, minister for Education and Science, said a decline in resources may not be the only explanation for this.

“There was a slight decline in citation index in the 1980s when resources were good. Why did the decline start then?�? he asked, saying Sweden needs to consider whether resources are used in the best way. Östros said reforms were needed, but pointed out difficulties in prioritizing research in the future.

He acknowledged Sweden has a weakness in supporting top research, but he also thinks it necessary to support research that does not reach top class. Both good and the not-so-good research groups should have their share of the priorities, according Östros. “We are a small country and must prioritize. In my view, the medical field is extremely important.�?

Within the medical field, Östros wants to strengthen clinical research, which is also a top priority for 2005–2008 for the Swedish Research Council.

The council wants to enhance public awareness and understanding of medical research, attract and recruit a new generation of researchers, work with other funding organizations, and promote gender equality and increase project support. Whether those priorities will cheer up the gloomy picture in Sweden remains to be seen.

warbi,

I stand corrected, I must admit that I haven’t read much about the recent research in Sweden.  Though, it seems that Sweden is taking steps to regain their past eminence in biomedical research.  So perhaps it would be too quick to discount them.

Hey, Socialist, that was about the only relevant link I could find on the search engines.  I must admit that you have piqued my curiousity though.  Could you point me in the direction of some information regarding ranking of countries’ medical research?  If not, no problem, since I have had little success!

I found a site that lists numbers of publications in medical journals by country (though that isn’t exactly a fair measure, because most people publish in American and British journals whether they are American, British, or not).  It also has a measure of the countries of origin for the articles, that’s a little more fair.  However, it still doesn’t account for the impact of the finds, just raw number of published studies.  The url is:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10352798&dopt=Citation

I’ll see if I can dig up anything else that is accessible to the public.

Yeah, I looked at a site that referenced the government site.  There was one that looked promising, but you had to pay for it.  This site has some fairly relevant and interesting information:
http://www.cms.hhs.gov/statistics/nhe/historical/chart.asp

The first pie chart shows that 55% of spending for healthcare in the US was private and 45% public (e.g., Medicare IHS, VA, etc...) The second shows where the money was spent.  Now these figures were for healthcare itself and not research.

It seems that no one keeps stats on where research occurs.  I think perhaps the best way to get a feel for things is just to skim some of the big journals like JAMA, BMJ, and Lancet and see who’s doing the interesting work and see where they’re working.

This is in reference to something upthread a ways, but we once had to sue an insurance company.  MrsDOF was injured at work, requiring surgery on both hands.  Other than the medical expenses (which they did everything possible to say weren’t work-related) the company wanted to stiff her for lost wages and disability.

Our attorney was a likable, earnest woman in sensible shoes with an old briefcase, a modest car, and an office full of papers. 

The insurance company’s attorney wore a $1K suit, Rolex, $500 shoes, and just seemed to glide from place to place. 

That miserable predator cross-examined my wife, twisting everything she said, confusing her, made her look foolish and just blew her out of the water.  Our attorney shuffled papers and asked a couple questions to establish facts that were on the paper. 

As a spouse I couldn’t come to the table at all so I just had to watch as that miserable predator cross-examined my wife, twisting everything she said, confusing her, made her look foolish and just blew her out of the water.  Our attorney shuffled papers and asked a couple questions to establish facts that were on the paper. 

I know the insurance company paid him more than we were asking for.  I felt like asking him: “Is that how you make your living, screwing a baker out of money for a disability caused by your client’s negligence?

I wondered, if I caught up to him sometime and smashed his manicured hands with a sledgehammer for humiliating my wife, would that be considered a work-related injury?

A slightly different case than suing for medical coverage but it was a window for me into how insurance companies think.

Doh!  I made a cut-and-paste error. Please ignore the duplicated text. Maybe I should go back to doing actual work now.

DOF, this ain’t gonna convince you of the saintity (or sanity) of insurance companies (I ain’t trying).

But from a purely economic point, it makes sense to pay that lawyer more than what you were asking for. By establishing precedent (both in law and in fact*) they reduce the likelihood of having to pay the next time such a case crops up. In fact, reducing the likelihood of such decisions even being challenged.

*like having such ‘scary stories’ told here. Mind telling the name of the insurance company? At least they should get a little negative press (as such as it is here) from it.

Oh, I understand the economic rationale - they’re not crazy or evil, they’re just making a profit.  Profit is fine from cars and beans.  It leads to absurdity and tragedy - like Les’ cousin - when applied to medical decisions.

The lawyer was paid by the insurance company to represent the employer.  It was a long time ago - alas I don’t remember.  They had a nondescript name, something like “Providence Assurance” or “Mutual of Transylvania.”