The Kaiser Family Foundation does frequent polling on a wide array of issues. They have a recent poll on politics and they probed a bit on what people actually mean when they say that they are concerned about health care. The key thing was personal costs and not systemic costs:
When asked to say in their own words what specific health care issues they most want to hear the 2018 candidates discuss, health care costs are the top issue mentioned by both Democratic-leaning health care voters (31 percent) and Republican-leaning health care voters (55 percent). The other health care issues vary in importance by partisanship. About one in five (18 percent) of Democratic health care voters say they want to hear candidates discuss universal coverage and about one in ten (11 percent) mention concerns about quality of coverage or care.
This is something that I need to remember as I am focused far more on systemic costs and insurance functionality instead of cost spreading functionality of insurance policies. Most people don’t give a shit that a plan with significant non-preventative services that are pre-deductible is bad insurance that puts significant cost sharing burdens on folks with chronic conditions and one-off catastrophes because most people don’t have a trainwreck of a year. Instead they barely touch the medical system so a $300 claim is a big personal deal or a $1,900 out patient procedure that is mostly going to land on their deductible is a massive expense.
This is just something that I need to keep in mind on the politics and lived experiences of health care financing.
In many, many cases, “Where you stand depends on where you sit.”
Thanks for your continued efforts to keep us informed on this stuff.
OT: Who do you like in the World Cup? i’ve been avoiding watching because FIFA is so corrupt and Vlad has his tentacles in it… :-/
My husband is on Medicare, and evidently he has hit the donut hole already. Yesterday he filled his Humalog short-acting insulin – it cost him $400! Last time he paid $120 for the same thing. It’s criminal that a common medication that’s been around for over 100 years costs this much just because drug companies keep changing the delivery system slightly, and no company manufactures an insulin with a delivery system that’s out of patent. He said he never paid this much last year, so obviously the price of the medication has increased. Gee, thanks Trump!!
True. If three other paupers and I are sitting in a bar and Bill Gates drops by for a beer, I’m not suddenly concerned about plutocrats’ issues because our average net worth is now $18 billion.
Especially since almost half of Americans can’t afford rent, a high co-pay means you’re effectively uninsured.
So true. My company just switched from a plan where prescription drugs weren’t subject to the deductible and started with straight-up co-pays to one where everything is in the deductible and you don’t even get to co-pays until you hit the limit. Which is ok for everyone who doesn’t visit the doctor more than twice a year, but I take three pills a day and for one of them the generic still costs out the nose. Not enough to ever hit the deductible, though. So I’m basically screwed.
As I’m still dealing with the wound which won’t heal, I’m tempted to tell the docs at the wound care center to go big or go home, have them charge me enough to hit the deductible up front, and pay the co-pays and such for the rest of the year.
Oh, and my company was telling us how great the plan was since it now includes an HSA we can put toward whatever costs we run up. Great for when your costs are at the middle or end of the year, not so much if they are right out of the gate.
Well, HSA’s ARE wonderful….if you have that kind of money just laying around to stick into it.
I’m not sure this framing is quite right. It’s not that people don’t care; it’s that they don’t understand it because it doesn’t affect them and it’s really complicated. There are so many insurance companies and so many different plans with different rules. It’s impossible for me to understand how my friend’s insurance works, which doctor they can see and so forth. I’ve recommended doctors to friends but they can’t see them because they’re not covered on their plan. Even something simple like “You’re looking for a doctor. I like mine. Here’s their contact info.” is complicated because your friend may not be able to see that doctor except out of network at high cost. It should be easy and it’s not. We don’t have a lot of bandwidth leftover to understand why this plan structure is better or worse than that plan for random groups of people.
I’d guess most people want their health insurance to work they way they want their cars or computers to work. They just want it to work when they need it. They don’t particularly want to have to be a car expert to drive from point A to point B or a computer expert to use Google or a health insurance expert to have coverage that doesn’t bankrupt them when they need it. They just want to turn the key / press the power button / show their health insurance card and have the whole thing work like it should.
That’s why “costs to me” is what matters to people. it’s so complicated that that is the only metric people really have to go on Does it work for me? Can I get treated when I need to?
@Luthe: Sorry you’re still dealing with a wound that won’t heal. How frustrating.
@BruceJ: Yeah. I lurv Rethug social engineering: well you put 3% of your pre-tax income into a HSA, 3% into a college fund, 3% into a long-term care fund that replaces Medicaid, 3% into the retirement insurance that replaces Social Sec., x% into the 401 because there’s no more defined benefit pensions…
@p.a.: and then they will gut regulatory oversight and allow Wall Street to steal the money you save.
This is exactly the problem with high-deductable plans. Most people will never hit the deductable, don’t understand that they benefit from the insurance company’s negotiated price, and say “This does me no fucking good at all. Why do I have to pay for it?”
Yesterday in the office I saw patient with HIV who is antiretrovirals drugs are now costing him $3000 per month after a change in insurance. Is over age 65, but hasn’t gone on Medicare yet because he’s still working. I encouraged him to moving to Medicare and to find a decent Medicare part D put in. I suspect this move will save him a tremendous amount of money.
@Luthe: Wish you all the best on that wound and sending healing thoughts your way.
I really do not see how most people cope with health insurance. It is quite bewildering at times. We would be much better off with universal coverage paid through taxes. Unfortunately, in the current political environment, it is almost impossibel to get there.
@Soprano2: Yes. I feel like someone needs to stand up for the consumers and go after these drug companies. The strength of all their patents need to be deeply weakened, and there need to be rules on how much they can jack up the cost of old medications. David usually discusses medication in terms of Quality of Life Years, but only people who are removed from these issues can do that. Most people look at it as “How much of my annual salary? Do we have to eat into savings for this?”
People care that their out of pocket costs are both unpredictable and ridiculous. The pharmacy I was using started using a different distributorship, and they are trying to sell us Epi-Pens that are good for six months. I have to buy six of these things that I will likely never use every year if they are good for a year. If they are good for six months, I have to buy 12. Each pack of two costs $600 retail. It costs something less than that with insurance, but is it $0 with the coupon from the company? Is it $100 because of the tier it is in with our insurance company? Is it $600+ which is the retail cost? Who the hell knows.
I am almost to the point where I am going to ask my allergist to just write me a script from a vial of Epinephrine and a needle because it is going to cost so much less. And I will deal if it takes an extra 30 seconds to stick myself.
I have been handling the benefits for my small to mid-size company for 20 years. After years of getting increases ranging from 5% – 7% on a good year to 30% to 100%* on bad years, there isn’t a lot left employers can actually afford to provide for their employees.
Most people don’t care how their individual actions impact larger systems or how systemic problems impact them, they just want their specific problem to go away. This is why leaders should be looking at the big picture and seeing how a lot of small infractions, like say littering, can lead to a large systemic problem or how a systemic problem, like ever increasing costs of healthcare, impact individuals and find ways to address these problems.
Unfortunately for America, one of the two major political parties is incapable and unwilling to think about anything beyond pleasing their pay masters and rigging things to win the next election.
* About 10 years back, prior to the ACA making high deductible plans the norm, we had to switch to a high deductible plan, because of an almost 100% increase in our premiums with a traditional plan. We had one employee with a brain tumor and one had premature triplets and those claims were enough to screw us.
** The only way I can see to bring costs down is to force the medical profession – device makers, hospitals, doctors, pharma etc. – to make less money. They need to take a hit for the good of the team, because they are bleeding us dry.
I am on a phosphorous binder. It is expensive. I found out the manufacturer offered coupons to help with the cost. But then the drug became a generic, before I could use the coupon. The insurance requires the pharmacy to use a generic, whenever possible, and the generic is no less expensive for me than the name brand, minus coupon.
What will it cost me?
The unanswerable question. We don’t know what our health year will cost up front. Even if you have major issues you don’t know. I do copays at the VA and I’ve had a copay year of just under $4000. My average year is about $1000. When I started at my last job, 25 yrs ago, we had no copays and a $200/year deductible. The changes in how health care insurance works over that time and that there are easily hundreds/thousands of plans means that no one has an actual handle on the situation. We have an industry insider here in David and he often admits that there are many moving pieces that he doesn’t truly understand. The rest of us are fucked.
Costs to the individual are all that the end user can see. And most of us are not complete nervous nellies, worrying about all the possible things we can do nothing about. If we were we’d be huddled in a corner, terrified to come out. I have a friend who is going in for a biopsy next week, he’s trying to not be in denial but that is self defeating.
Health care itself isn’t all that easy to deal with, the complexity and cost of the payment system makes it far worse. And I’m sure that’s by design. If it’s easy, most anyone can understand and work within it. If it’s complex, at some point, a lot of people will just ignore it. Which is for the same reason that simple slogans work for politics, many people just don’t want to do the work. And they only don’t ignore it when their personal or favorite ox is getting stabbed.
What that one party is mostly worried about is that the money flows into their coffers and not out and that the people carting that money into their pockets is all white or all slaves. I’d bet that if they could arrange it so that all the slaves were white as well, they would be fine with that. IOW to them, the only color that humans come in is white.
@gene108: I don’t think companies should be offering health insurance at all. I know how it started and why. It was a benefit because they couldn’t raise wages. That’s not the case now and it clearly is a burden on companies, especially on smaller companies. Decouple work and health insurance. You don’t get your car insurance or your house insurance through your company. Health insurance shouldn’t be done that way either. It’s an antiquated structure that needs to end.
@Ruckus: No one knows what their health costs will be. We can all get hit by a bus or a bad diagnosis. Even when you work hard you can’t find the costs of something.
I’ve told this story before–I had a doctor prescribe a test. It was semi-optional but it would help find out more about an issue I was having. Before I went for it I wanted to know what it cost. I spent hours on the phone over two days trying to find out the cost. I had the exact CPT code and the exact place it would be done. It was in-network. And NO ONE could tell me what it would cost. No one. How can you decide if you can afford a procedure when you have no idea what the cost will be? $50? $500? $5,000? Who knows? I did the work. I talked to everyone, from the insurance company, to the doctor’s office, to the company reading the tests, to the go-between company that’s supposed to be able to sort it out for you. Not one person could tell me the cost. That is just wrong.
sheila in nc
That’s really the bottom line. It’s also what Uwe Reinhardt kept saying. All the contortions we put ourselves through policy-wise are just a way to keep people alive floating at the top of an ever-increasing flood of medical profit. It’s also a big reason why our US medical system is so much weirder and less effective than other nations’.
I have Crohn’s disease and had been on immunosuppressive drugs for several years, some of which (Humira) were fairly expensive. Then I got diagnosed with lung cancer and had to stop the immunosuppressives. I’m on a new drug now, Entyvio — a much better molecularly-targeted infusion drug, and I’m responding very well. But the infusions have to happen every two months — presumably for my lifetime — and they cost $14,000 each (at least, that’s what Blue Cross gets billed, but not what they pay — not even close.)
Another point: the greater the inequality between the overall costs of the system and the discretionary funds available to most people, the more often you will reach financial “pain points” for even middle-class patients, not just poor people. Looked at one way, my co-pay or whatever for these infusions is a minimal part of the overall cost. However, just a little change makes a big difference to me in terms of out-of-pocket. (My personal cost has varied from $320 to $730 per treatment.) And Entyvio is not the only drug I’m being prescribed.
So I feel really bad, on one hand, that the needs of people like me are driving up costs for everyone else. OTOH, the needs of people like me are totally legitimate! I think there are over half a million people with Crohn’s in the US today.
One other thing that my husband keeps pointing out — any solution we come up with to reduce provider costs to patients/consumers will have to include a plan to subsidize or reduce the costs of medical training. But that’s another whole financial system in itself — tuition paid by medical students contributes a lot towards supporting academic medical centers.
My favorite part of health care coverage continues to be that wackadoodle job benefit Ohio Dad gets, where he can put part of his salary aside tax-free for costs the insurance doesn’t pay but he has to guess at the beginning of the year how much to put aside.
If we don’t use it all by the end of the year, we forfeit whatever is left. If he doesn’t pick a large enough amount, we come out behind as well (though it is less obvious).
It’s like the insurance company is double-daring each year, we’re being forced to bet against their actuaries.
I am resigned to the fact that the entire health care coverage system is totally corrupt. We pretend it’s fixable, which implies a certain legitimacy, because fish don’t know they’re in water. But it is one of the most corrupt things going on the planet.
@Luthe: And we were all so optimistic when you were referred to the wound specialists — I remember that thread well — we thought that was going to be the answer.
Is there a teaching or research hospital that is known for wound care, that you could travel to for a second opinion? I know from my cancer adventure that cancer patients sometimes travel out of state to consult, particularly if they have something unusual. (I didn’t because I had the most garden variety type).
It would not be hard to mandate that all health insurance have a drug deductible of no more than $250 a year, and copayments for drugs limited to $250 a year. I believe California has made moves in that direction.