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Acts of Corporal Charity, 2

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So, Jem asks:

>>>>Are you saying that: a)we would be better off with the health care and insurance costs we now have b) that any health care reform that doesn’t include a public option does not serve the nation as a whole or c) that making health care insurance mandatory will result in unemployment for more people?>>>

And Cheryl is worried about the negotiating aspect.  So let me try to take everything in order.

First, do I think we would be better off with the health care and health insurance costs we now have?

Well–better off than what?  I think the bill as now written would make the cost of health care and health insurance worse, in the long run.  I think it will end up making health care more expensive and leaving even more people uninsured. 

But I don’t much like the system we have now.  In a way, it’s the worst of both worlds–all the drawbacks of a public system and none of the advantages. 

Second, do I think that any health care reform that doesn’t include a public option doesn’t serve the nation as a whole?

No.  There are forms of health care reform without a public option that would make things better–something like that insurance for catastrophic care only, everything else paid for by tax-exempt (or credited) MSAs (medicaal savings accounts) would probably make things better, because that would be an actual free market in basic health care services.

But this bill will only make things worse if there is no public option in it, because it forces us to deal with insurance companies that rip us off at every turn, thereby letting them go on ripping us off with impunity.  After all, what could happen?  If there’s a mandate, it’s not like we can refuse to deal with them and punish them in the pocketbook for their behavior.

Third, do I think that making health insurance mandatory will result in unemployment for more people?



Do the math.  If I’m a small business with $300,000 a year to spend on my workforce, and I employ 10 people at $30,000 a year, but do  no provide health insurance coverage–then when the government demands that I do provide that coverage, I must spend $10,000 a year EXTRA on each employee I hire.

But I still have only $300,000 to spend on employees.  That’s all the business can afford.

What do Ido? 

I fire as many employees as I need to to make up for the fact that each of the employees I have left now costs me an extra $10,000 he didn’t before.  Instead of employing 10 people, I employ only 7.

And, what’s more, I make sure to limit or eliminate, as far as possible, unskilled employees–I cut back on receptionists and put an automated system for most calls, for instance–because they’re the people I can most easily do without. Meaning there’s not just more unemployment, but the rise in unemployment hits the poorest people first, and disproportionately affects minorities. 

Most of the companies in the US that provide employment are small businesses–and a mandate for them to provide health insurance for their employees willresult in lots, and lots, and lots of firing.  It has to.

Fourth, do I think a public option would have to cover illegal immigrants?


And I think that means that if we have one, we will have to restrict immigration generally and come down hard on illegals. If we don’t, we’ll see a lot of immigration specifically targetted at taking advantage of the welfare systems, and that will bankrupt those systems in no time at all.  That’s a drawback to any significant welfare system. 

I do know that it’s expensive to pay for health care on  your own–I suppose my basic response to that is:  so what?  It’s expensive.  A  lot of things are expensive.  I don’t see anything wrong with people paying out of pocket for health care, any more than I see anything wrong with people paying out of pocket for food.  Both are necessities.  We usually do expect to pay for the things we use.

As for the situation in Florida for hospitals–there is only one public hospital in CT.  All the rest–every single one of them–are private.  The vast majority are also not for profit.  And they make arrangements.  So do doctors.  For profit hospitals are a different animal, but I haven’t dealt with one. 

As for Cheryl’s problem with negotiating–you don’t negotiate when you’re sick, but after you’re well, and the reason for that is that health care is not like buying a car.  There’s a reason why I called these posts “Acts of Corporal Charity.”  Tending to the sick is always an act of charity, even when we fund it through a government program.  It is always the case that tending to the sick means helping people who do not have the resources to help themselves. Sick people don’t work. They spend down their assets.  They can’t give us much in exchange for caring for them. 

The hospitals I deal with are private not-for-profits that get tax breaks–in fact, are free of taxation–on the assumption that they provide a charity for the area in which they exist.  They’re not businesses whose purpose is to make a profit. 

Even if you’re insured, the chances are that the fees your insurance company pays for the procedures you get vary wildly from what other companies pay that same hospital for those same procedures.  All fees in US health care services are negotiated.  None of them is a standard price charged to all comers–and the stated price for people not insured is often far higher than what insurance companies pay.

If the insurance companies can negotiate down those fees, I don’t see why it’s dishonest for me to do it.

Written by janeh

March 15th, 2010 at 10:28 am

Posted in Uncategorized

5 Responses to 'Acts of Corporal Charity, 2'

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  1. Negotiation. Why is that such a bad word in the western world? We do it for cars…we do it for houses. Why not for medical care?

    Confusing negotiation with conflict or adversarial confrontation, or even aggression gets us into a lot of trouble, I think. There is so much paranoia over confrontation, especially among women, it almost amounts to a pathology. (sorry Jane) They’ll do almost anything to avoid it, even, if I’m understanding Cheryl correctly, die rather than seek medical care they think they might not be able to afford.

    Rather than looking at negotiation like that, look at it as a discussion of value for value. Businesses price their goods at what they ideally want to get for them, but they almost all have a margin in which they can still make a profit, but can make the sale attractive to the buyer. This is where “sale prices” come from. Never think a business that can cut prices by half during Sale Days cannot cut a margin significantly any day of the week and still make a profit.

    Health care has a HUGE margin. There are practically no market controls on what they charge. A fabric store, say, generally has a certain markup to stay competitive with other fabric stores. It doesn’t vary much among competitors. Health care, on the other hand, can vary wildly based on demographics of patients, for- or non-profit, teaching or non-teaching, a wide range of factors for the very same procedure.

    ALL doctors/hospitals put a price on their services far beyond what it actually costs them. I would say that they actually *get* those prices almost never, except from individual patients so intimidated by the concept of saying “Can we adjust this bill at all?” that they choke up. Every insurance company negotiates with providers. Most patients know they can, too. They may or may not choose to, but they can.

    The price a doctor charges is NOT WHAT THE ITEM IS WORTH. It’s what the doctor wishes she could get. If you have that value discussion with the doctor or her staff, you can arrive at something where she gets what she needs, and you get what you need, at a price you can afford.

    And yes, you can do it after you’re well, not in the throes of illness. Nobody can or should try to negotiate while ill. It’s hard enough choosing the best treatment options.

    I do beading now, trying to make a side-business of it. I’ve found that almost without exception, if I make a sizeable purchase in a bead store, there is a 10-15% discount to be had, if I just ask. No hassles, no offended feelings, just “in return for this large purchase, can you adjust your margin for me?” If I get turned down, or they offer a smaller discount, then I accept that. Also with no hard feelings.

    I’ve tried this same technique in many other areas, and it works, almost every time. The price is almost never The Price. And what you think is the price for health care is certainly never The Price. Don’t let that consideration keep you from seeking care you need.

    All health care is sought when needed, and then paid for later. Using what you need when you need it is not stealing. After all, they’d rather have a live patient who owes them money than a dead person who hasn’t ever sought their services. They know that if they impoverish you, you won’t be back. Like all providers of services, they know that killing the chicken may get you cacciatore today, but eggs will be in very short supply forever, and there won’t be any more chickens.

    Negotiation is not “gaming the system.” It *IS* the system, but too many people are intimidated into thinking they can’t do it on an equal basis.


    15 Mar 10 at 12:22 pm

  2. It is not so much the negotiation – although I do hate doing it, and rarely try (in spite of having once lived in a place where it was required and expected for everything). Negotiation does intimidate me.

    That was more or less a side point, and not what I was calling ‘dishonest’. What I was calling ‘dishonest’ (and I know that’s a strong word, but I’ve been trying to restrain myself because I know there are other views on the subject) was me obtaining goods and services that I KNOW I can never afford and never pay back, and that my closest relatives, should any of them survive me, can’t pay back either. And for a very serious illness, that’s the kind of costs that are under discussion. It doesn’t matter to the way I feel if this is the way everyone does it and all I have to do is call up the hospital or doctor and offer some payment I can afford that won’t pay off what I owe even if I survive the illness and continue working and earning money for another twenty years or more. I am obtaining benefits without paying, and knowing I can’t pay.

    And I have no objection to various businesses offering discounts up front – for bulk purchases, for cash (unless it’s an attempt to do business under the table), for senior citizens or children. I don’t like it when there’s a ‘discount’ if you don’t have insurance (we have that in Canada to a certain extent for things not covered by medicare). If a dental procedure costs $X and you get it for $X-10% because you don’t have insurance, then my insurance premiums are higher because my company is paying the higher price. I wouldn’t have the slightest problem with the 10% discount if it were offered on the basis of something like age, and stated up front (I think I’m creeping back towards discussing negotiation again…)

    I think my very strong negative feelings towards this kind of arrangement have something to do with charity. I have accepted charity, very gratefully, but on the whole, like most people, I’d rather give it than take it. I want to pay my own way. I don’t want to have to beg for medical care as a charity, especially if the charity is disguised as a break on the price of something – and most especially when I have no way of knowing what the true cost and profit margins are, and when I am certain that the real costs of, say, treatment of terminal breast cancer, would be way beyond my means in any case. I don’t know if I would hold to my convictions if I were in the US and suffering from terminal breast cancer, but I do know that I’d want to pay the cost of my care, and I certainly wouldn’t want to leave a financial mess for my next of kin to take care of if things didn’t work out – and that if I were working at a similar income to mine in the US, I’d never be able to afford any financial accommodations that came close to covering the cost. I probably wouldn’t be buying the routine meds my private insurance here covers if I had to pay full price! I’d take my chances.

    I feel comfortable about medical costs here. I’ve been paying in and taking comparatively little out so long that I wouldn’t feel guilty at taking something I wasn’t entitled to if I did, God forbid, get something protracted and expensive. I don’t abuse the system, and if a few hypochondriacs make unnecessary visits paid for by my money, I’m not worrying about it. And if I do have to have something expensive and uncovered done – say, a dental procedure other than routine stuff – I get a pre-determination before I agree to the treatment.

    And if I died suddenly without requiring much in the way of health care, the balance of the money I paid in is there for someone else to use.


    15 Mar 10 at 12:49 pm

  3. Can’t argue a bit with Jane’s logic on this one. The bill seems calculated to drive costs up, and the recent interest in “cost controls” only on the insurance companies would make this worse. Does anyone else remember the Federal government dictating conditions of service and prices for railroads until every railroad in the northeast went bankrupt? Nothing like authority without responsibility.

    In fairness to his Oneness, a number of provisions which might reduce medical care costs are included–but except for the sale of policies across state lines, all of them are “pilot programs”–CongressSpeak for “we’ll do the painful stuff later, honest.” Sadly, the person who assures me Congress will come back later and institute medical courts or reduce “pain and suffering” awards is also the man who told me this was the last time “health care reform” would need to be addressed. But I suspect that in mentioning this I’m adding to the Fog of Negativity. (Isn’t that somewhere in Bunyan, by the way?)

    [Please everyone remember this when it seems as though I only coment to disagree.]


    15 Mar 10 at 6:16 pm

  4. Welcome to the Contrarian Club, Robert. I’m a charter member. :-)


    15 Mar 10 at 8:09 pm

  5. Cheryl wrote: “If a dental procedure costs $X and you get it for $X-10% because you don’t have insurance, then my insurance premiums are higher because my company is paying the higher price.”

    Actually, that’s almost perfectly backwards. The doctor asks for $X. The insurance company has negotiated with the doctor for $X – 50% (or more discount than that). That’s what the doctor accepts. If you pay $X, or even $X-10%, YOU are the one subsidizing both the insurance and the non-payers. What you’re asking the doctor to do is give you a rate closer to what he accepts from insurance.

    The way I consider it, the doctor gets his money Right Now, not 3-6 months from now, the way most insurance pays. He doesn’t have the staff costs of filling out insurance forms and submitting them, and tracking the payment (or not). So it’s worth it to him to discount heavily. Because it’s clear that even at insurance rates, the doctor is making a living, paying his staff, etc.

    Attitudes about acceptance of anything resembling “charity” are very ideosyncratic, and may be formed young. What I have found is that often those in the health care area really *like* helping people, when it has nothing to do with money, and if you don’t give them some opportunity to do so, they feel like they’re serving hamburgers or something. When I have needed help, I have asked for it, and I saw first hand that people who help *feel good about themselves* for doing so. My need enabled their feeling good.

    That’s why lawyers work pro bono. That’s why there is Doctors Without Borders.

    And I figure that now that I am in a position that I can help, I do so. In a way, I pay back everyone who helped me by helping others. Kindness breeds kindness. If no one ever wants to accept “charity”, then this entire facet of human experience becomes moot. Note, I do not advocate living off of others or abusing the system. I only say that giving a gift *must* be reciprocated by accepting a gift. For some people, gracious acceptance is very very difficult. Something about “obligation” or unworthiness to receive.

    There’s nothing unworthy about being in a situation of saying “I’m unable to pay full freight for what I need right now. I may never be able to fully repay it. But I need it, and I’m a human being. I will pay as I can, I will help as I can in return. Will you help me? Thank you.”


    15 Mar 10 at 10:06 pm

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