Cuban healthcare

by Finn

With the death of Fidel Castro, the healthcare system in Cuba has received some attention.

How Cubans Live as Long as Americans at a Tenth of the Cost

What parts of the Cuban healthcare system do you think could be adopted here?

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197 thoughts on “Cuban healthcare

  1. I didn’t get to reply to the vaccine post the other day, but I’d be in favor of making vaccines mandatory, at least if you want to attend public school and/or receive government health benefits. The stuff about making primary care more accessible vs. ERs also makes sense, though don’t know all the details about what that looks like on the ground.

  2. First, thanks for posting this. Very interesting and something I was unaware of.

    I like the idea of the annual meeting with your doctor in your own home. (recognizing that to accomplish that the Cubans have 2x/capita the number of primary care physicians we have). Is that because there are fewer specialists/capita? maybe so because with so much better primary care stuff gets caught before a specialist is needed. So it could require a shifting of doctors out of specialties and into general practice if we had the political will to implement here. I think Cuba also has a lot more influence (i.e. strongarms) docs into practicing where they’re needed vs where they want to.

    “Congrats on your new MD degree; the clinic in Elko, NV is expecting you on Monday. You can move into your (state-provided) housing on Saturday; here are your travel documents. Oh, you wanted to live/practice in Chicago, where you’re from? Well, we have enough doctors there now but you can get on the transfer list and when we need you, we’ll call. Meanwhile, enjoy Nevada.”

  3. “Congrats on your new MD degree; the clinic in Elko, NV is expecting you on Monday. You can move into your (state-provided) housing on Saturday; here are your travel documents. Oh, you wanted to live/practice in Chicago, where you’re from? Well, we have enough doctors there now but you can get on the transfer list and when we need you, we’ll call. Meanwhile, enjoy Nevada.”

    This is what the Army does.

  4. I believe the same is true in Australia – you need to put in your time (as an independently practicing physician) in the rural areas before you are allowed to have a full license that allows you to practice anywhere.

    Fred – I believe you are making the common mistake that a specialist is a primary care doctor + more. You can not ask you ENT to treat your sore knee, or your vaginal discharge. One cannot shift doctors out of the specialties and into primary care, except at the training level.

  5. In a totalitarian state, noncompliance is not an option. Athletes are directed to sports training and their sport is selected for them, academically qualified students are directed to medical school and their practice are and geographic location is selected for them, etc. Refusing medical care is not an option. Care is rationed and financed for the greatest overall benefit. Outside of a few individual cases, travel off the island for specialized medical care would be both impossible financially and not permitted politically.

    None of this is acceptable in the US.

  6. Whenever these issues are discussed, I think we need to keep in mind the role of the US in medical innovation. A huge virtue of our system is how we create novel technologies in the medical space that then benefits the world. I think it is very hard to compare a small, homogenous country that has very little of that to the US.

  7. Fred – that’s also the basic deal in Canada, or it was when I was there. They didn’t assign you to a place exactly, but they wouldn’t give you an OHIP billing account in your chosen area if they were saturated will billing docs there. And they’d offer, “But we DO have OHIP numbers available in [fill in name of town 18 hours north of Toronto].” A friend of mine wanted to do a certain specialty, figured out she’d never be given a billing number for that speciality in the city she wanted to live in, figured out the speciality she could do in that city and switched emphasis in medical school. It seemed less than ideal to me.

  8. Ada, I get that completely. My point is for us to build a Cuban-esque system, we would need to start at the the med school level and first train everyone as a generalist. Specialist training would be much more limited than what we have now.

  9. It’s also important to consider how different countries calculate life expectancy and what resources they put into treatment for drug and alcohol addiction, obesity, etc. Most countries don’t include babies born before 28 weeks gestation in their life expectancy statistics. The U.S. includes babies born between 24 and 28 weeks. A decade ago, the U.S. had the best infant mortality rates in the world if you included all babies born after 24 weeks gestation. As a matter of resources, I don’t know if it’s better to care for babies born 24-28 weeks or let them die, as many countries (including parts of Europe, officially or unofficially) do, but such decisions dramatically affect healthcare costs and statistics.

    I never like a focus on mortality statistics when so much of our medical care involves treating problems people wouldn’t die from so they can live fuller lives.

  10. I have a friend from Central America. My friend has not lived there in 30 years, so I don’t know if the system is the same. When she was growing up both of her parents were doctors and both specialists. Regardless, both had to put in a fixed number of hours per month in a public health setting as it was required service to renew your license. There were a variety of ways to fulfill this service, but her dad would go to the interior of the country where he grew up at the end of one month and stay until the next month to cover the hours for two months and work in the local clinic. People trusted him more because he was “from there” and he would stay with relatives so his only real cost was transportation. His situation was fairly unique because most physicians didn’t have a routine place they gave service. For most of his peers, his preferred choice was their Elko, NV. The result was their way of expanding the access to care for a large part of the population.

  11. Historically, in the US, there hospital call system created an obligation to care of the indigent. That has changed with the advent of hospitalists as well more office-based specialties and outpatient surgical centers.

    In the Good Old Days, person without insurance presents to local ER. She needs her peritonislar abscess drained, her lower intestinal bleed managed and will require admission to the hospital. In these very good old days, there is only one GI doctor and ENT and a few dozen primary care doctors. The ENT and the GI doctor rely on the hospital as a place to do procedures, the hospital requires that they take call – picking up indigent and insured patients. The primary card doctors take community call – every few weeks they agree to take responsibility for any uninsured patient that presents to the ER and requires admission. All of these docs will continue to see the patient in follow up.

    Now, the ENT has her own surgery center, the GI doc doesn’t do any hospital based procedures. If their patients are admitted to the hospital, the hospitalist takes care of them, or if they need a specialized doctor transfers them to the tertiary care center. They don’t take any kind of call anymore – they don’t need the hospital, even though the hospital needs them. The hospital employs hospitalists to manage all of their inpatients on the general medical ward, so the primary care doctors are not taking community call anymore. (In high school, I would sleep at a pediatrician’s house once in awhile – her DH worked an overnight shift and she had to be on community call for admitted pediatric patients who did not have primary care. She had to have the ability to go into the hospital if required, so I stayed with the kids. This wasn’t so very long ago. I’m sure she doesn’t do this anymore.)

    Anyway, we used to gently spread out the indigent over most of the doctors, now we concentrate them at tertiary care centers. We have also made health care so prohibitively expensive compared to other goods and services, and compared to wages – an uninsured patient with a minimum wage job cannot put appendectomy or c-section on a payment plan and expect to ever pay it off.

  12. I’ve always wondered if the Cuban healthcare system is really all that good, or if they just give us glowing statistics. I think all that hype about the Chinese barefoot doctors in the 60’s was just that : hype.

    We would be a lot better off looking at France and Germany, which do objectively run first class healthcare systems more cheaply than we do.

  13. The problem that always existed with hospital based charity care was that it didn’t work well for people with chronic healthcare needs because it was mainly based on treating urgent and was very episodic. Hospitals were never required to provide longer term care or followup to uninsured patients.

  14. I would also like to point out the general absence of processed food and good television. They may be more but they eat less crap than our poor, they are more active and have stronger social ties than we generally do. All things that lead to good health outcomes.

  15. There are a couple of simple things we can do to address the shortage of primary care doctors. The easiest is to increase the number of residency spots. Another is for Medicare to increase reimbursements for primary care, and the private insurers would likely follow. There is no incentive for docs to go into primary care because all the money is in the specialties.

  16. The problem that always existed with hospital based charity care was that it didn’t work well for people with chronic healthcare needs because it was mainly based on treating urgent and was very episodic. Hospitals were never required to provide longer term care or followup to uninsured patients.

    That’s still a problem. I read a great article a couple of years ago about a homeless person who was constantly calling 911 to the ER. All the docs and paramedics knew him. He kept saying his throat felt like it was closing up and he couldn’t breathe. They never found anything wrong with him and figured he was just making it up and would discharge him. They figured he was costing the city probably six figures every year. Finally one doc decided to take him on and figured out he really did have an undiagnosed medical condition, and she was able to treat it and cure him.

    It’s much cheaper to provide ongoing primary care than it is to provide emergent care, but any system would require some form of socialism at its base. In the same way, some economists have calculated that it would be cheaper for cities to simply provide free apartments for the homeless instead of trying to deal with the problem as they currently are.

  17. I’ve always felt like in this country there should be a way to establish the basic level of care to which every person is entitled simply because they are human and we can afford it. I know that is easier to say than to do but at the same time we certainly ought to try.

    We should also find ways to encourage MDs to accept Medicaid patients. It is a hard group to serve given that they have a high no show rate and they will not reimburse for no shows. What kind of fool would choose to base their business on that?

  18. PUH LEEZE!!! this is what enrages people about the American Left- the willful ignoring of all manner of horrific goings on and “intellectual conversations” about the various good points of a communist tyrant. I also find it kind of bigoted in the way that maybe “those people” don’t need the freedom to pursue their own professions be paid for them, and enjoy democracy. You know Mussolini made the trains run on time, let’s discuss how he did that – maybe we can learn something from that.

    You know the Castros had all AIDs patients forced quarantined?

  19. Mafalda, I think I was trying to point out my suspicion of their statistics. I don’t think Cuba is a model for us for bunches of reasons. However, I do think we should be looking more closely at successful healthcare systems in other wealthy free nations, instead of galloping off towards a model completely untested anywhere.

  20. This has interesting stats on the state of the cuban economy – I believe you would potentially be more likely to be sent out of country rather than a rural area if you are a doctor in Cuba.

    https://hbr.org/2015/08/what-you-might-not-know-about-the-cuban-economy

    “So how does Cuba make money? Its current principal source of revenue is the export of healthcare services by means of sending physicians, nurses, and healthcare technicians to countries like Venezuela and Brazil—an item that it has yet to record in its published official statistics.”

  21. No, come back, Mafalda! We need your perspective.

    I have some of the same reactions to my more-leftist friends who worship the Scandinavian countries. Do you know how many individual freedoms are curtailed over there? You wouldn’t put up with it for a second. And they’re not even in the same ballpark as Cuba.

  22. I do believe basic healthcare should be a human right in this country and the ACA didn’t help enough. I would have gone single payer and had more doc in a box type set-ups for family practictioners and better use of technology (for medical history, prescriptions, etc.) to provide improved care. That plus telemedicine for specialists assisted by the local PA, MD or nurse practicioner would be much more efficient and cost effective.

    Sort of on topic: What is driving the proliferation of free standing ER’s? Did we have unmet ER demand? There are four within 2 miles of my house that are new within the last year.

  23. We should also find ways to encourage MDs to accept Medicaid patients. It is a hard group to serve given that they have a high no show rate and they will not reimburse for no shows. What kind of fool would choose to base their business on that?

    It’s not the no-shows that are the issue, it’s the low reimbursement rates for the actual visits. If you want MDs to see Medicaid patients, then reimburse at the same rate as Medicare.

  24. What is driving the proliferation of free standing ER’s? Did we have unmet ER demand? There are four within 2 miles of my house that are new within the last year.

    You have to ask? Money. ER visits are reimbursed at a very high rate.

    Mobile ER services are the future – https://www.dispatchhealth.com/ They can handle about 80% of ER visits in the comfort of your home for a fraction of the price.

  25. I find it hard to comment on health care related topics, because my thoughts are SO BIG.

    But, I find myself in favor of a single payor system – something I never would have thought several years ago. Not so much because I think it’s a basic human right, but because I’ve become convinced its the most efficient and effective way to provide a service we as a country are already providing.

  26. “What is driving the proliferation of free standing ER’s?”

    Money. Specifically, UC/UMC money — people who don’t want to wait for 3 hrs at the ER with all the riff-raff, and who have good enough insurance not to worry too much about the cost and/or can cover the overage when they realize, oops, it wasn’t actually an urgent-care clinic after all.

    The ER will generally bring you down to size — it is a leveling experience, like the DMV but with pain. I spent a lovely 2AM there (and 1 AM, and 12 AM, and 3 AM . . .) when I hurt the cartilage in my back a few weeks ago. Worst pain since childbirth, and of course nowhere remotely comfy to sit. After about 2 hrs of waiting, I realized: they don’t care how much pain I am in, because my injury is not life-threatening; they are triaging (as they should) based on potential severity/immediacy of the issue, not whether I hurt a whole bunch, or whether I have good insurance, or any of the other stuff that usually allows me to avoid most nastiness/annoyance. So much for my inflated view of my own importance.

    That night I would have happily paid someone $200 to take me back right away. Or $500.

  27. LfB and Lark both make good points. To what extent are those of us who are “advantaged” (with access to providers, due to medical insurance and where most of us live) willing to sacrifice in order to provide basic care for all?

    I agree with Mooshi that France and Germany have reasonable compromises between access and quality and they are systems that are worth emulating. Geography/population density is the main challenge we have that they don’t.

  28. I like the Vox article. I lived near Corbin, Kentucky, for a few months. One of my issues with the affordable care act is that it covers preventative care (like mammograms) but no follow-up care without the $6000 deductible, so it only covers preventative care for healthy people. I also think the law that limits the price differential by age to 3x is problematic if the real cost difference by age is 6x. This ties into my previous observations that young, working class people can’t afford to further subsidize healthcare for older people.

    I don’t know how a private market would work if the federal government (via income taxes) paid for the healthcare for the most expensive 3% of the population after insurance had paid out, and focused cost savings work on that most-expensive group. I’ve read that 1% of the population accounts for 30% of healthcare expenditures. It certainly seems better than excluding working class children from public school because their parents don’t have $3000 for the required childhood vaccine regimen.

  29. Freestanding ERs are a revenue generator. They typically are in places which do not have great bus service, and are easily only accessed by people who are upper-middle-class and have good insurance. The one I worked at didn’t even keep a list of low-cost or government run primary care clinics ( A staple document and any other emergency department).

    As LFB mentions, many of us are willing to pay a premium for care when we have a non-life-threatening but inconvenient or severely painful problem. For patients who are well insured, the difference in cost between an ER visit and urgent care visit might be less than $100, or might be nothing at all. In general, these facilities see urgent care patients and bill them at emergency department prices. The difference is likely a few thousands of dollars per patient. Urgent care visits typically are priced at around two to $300. ER visits are usually a minimum of two to $3000.

    Most freestanding ERs have very high utilization of CAT scan and MRI, as these are additionally billable services. They are also huge patient satisfiers. In my experience, less than 10 or 5% of patients in a freestanding emergency department require hospital based services. They tend to have very low admission rates, lower than some urgent cares.

  30. @WCE: I think the question is even harder than that, because I think the fact that we are advantaged tends to be hidden, even from ourselves; I mean, I am aware of it at a theoretical level, but I needed to sit in that ER in huge pain and with no other option to remember what powerlessness actually feels like, and to see how far my “normal” now is from the folks in the article Rhett posted on the politics thread.

    In other words, I didn’t feel “advantaged,” I felt “normal.” And I think people tend to tighten up and get defensive when you ask them to give up something they see as normal and something they have worked for, presumably to benefit people who don’t work hard and expect things to be handed to them (channeling the resentment from Rhett’s same article).

    Personally, yeah, I’m happy to pay more taxes in order to provide basic levels of care for those who can’t afford to. But I think it’s an uphill battle.

  31. Accessing primary care is difficult for people, who for financial reasons, need to access it outside of the shortened business hours that seem to be the norm around here. Most physician’s offices seem to be open 8:30 am to 4:30 pm, taking the last appointment around 4 pm, plus close at noon or all day one day M-F, and no weekend hours. The dynamic is very much that you need the doctor more than the doctor needs you as a paying patient. As a result, the patient contorts their schedule to meet that of the doctor and is expected to be “happy” even if they have to get there 15 minutes before their appointment time, but aren’t taken back until 30 minutes afterward. But, if they are 15 minutes late, their appointment is cancelled, they have to pay for it, and reschedule it for another day.

    When you are only paid when you are at work and must rely on (at least in my city) rarely on-time public transportation, accessing the primary care is harder than it seems on the surface. While our “community clinic” that takes medicaid, CHIP, and other sliding scale patients is open from 7:30 am to 9 pm M-F, wait times are long and the online reviews are awful.

  32. And one freestanding ER where I worked for a while, we saw a high number of patients from a certain large company that was known for its generous insurance plan. The insurance plan had very low co-pays and reimbursed doctors well. We (the various medical centers) were all competing to see as many of these patients as possible.

    It was common to see a child who had a fever for a few hours, or a simple sprained ankle. Lots and lots of care was provided for pinkeye. We provided convenient and fast service. Eventually, the large employer changed the terms of the insurance so that the patient had a higher ER co-pay. They were spending thousands of dollars per day reimbursing for primary care delivered from the free standing ER.

  33. LfB, it’s a hard question. When RMS talks about people who think their success is due “solely to their own efforts”, I think, “What reasonable person thinks (s)he would be equally successful in North Korea? All of us recognize that our success isn’t due 100% to our own efforts.

    The more relevant criterion for giving assistance is something like “works at least as hard as I do” or “has disadvantages I can perceive that keep him/her from working as hard as I do”. The “disadvantages I can perceive” is probably what places people on the spectrum. I don’t perceive addiction, for example, as a “disease”. It is, at least in part at the beginning, a choice.

  34. I agree with the anon at 1:12. My understanding is that there was a change in billing regulations about a decade ago. There used to be a modifier on billing codes where doctors could be paid extra for care provided after hours on the weekends. This was removed. It deincentivized any kind of after hours care, at the same time doctors felt like they were being asked to do more during the regular hours.

  35. I had a friend who went to Cuba on a medical exchange earlier this year. She said they basically got escorted into a conference room, were locked in, and had to watch propaganda videos or gave presentations the whole time. Didn’t get much of a tour of the OR or hospital facilities like they were promised (ran out of time). She came back a bit shellshocked from being followed by minders the whole time.

  36. Yes but it is like an example of a classic supply and demand curve. Are none of these people doing market studies to assess depth of demand? There will be a point of equilibrium with wait times and cost and about half of these will fail (and that’s before you talk about potential wholesale change of healthcare ….i.e. repeal of ACA). I could see needing two more but there aren’t enough rooftops to support four of the exact same concept.

  37. To WCE’s point – A lot of people (at least in my neck of the woods) think that your success is 80% your own effort and 20% who you know while your failure is 100% your fault. Only a high school education, homeless, food insecure, etc. are all the result of choices you made.

    Empathy is low. Criticism is high – Free breakfast as school is met with can’t “these people” even feed their kids breakfast? Programs to help first time college attendees navigate the process is met with why isn’t this available for every kid, my MC/UMC could benefit too.

    But, these are the same people who will push their kids toward the motions of community service to make their college resumes look good.

  38. Ada makes a good point about the timing of reimbursement as a factor in access.

    I was talking to a young, retired OB/GYN at church this week who retired in part because he didn’t like dealing with his disadvantaged patient population. They don’t shower regularly, they don’t follow instructions, they overuse drugs/alcohol and are eager to sue if anything goes wrong. With insurance company evaluations of “physician outcomes based on patient outcomes/readmittance”, he’s blamed for all this. He decided he was just done.

  39. MiaMama- you might be right. However, it’s possible that demand will increase given the increase in supply. People who may have not sought medical care will go if it is convenient. I think there’s a study of telemedicine to this effect. People who use telemedicine are happy with the outcomes, but it turns out if they didn’t have the opportunity, they would’ve waited out their symptoms. And most of the time they would’ve been just fine.

  40. The hours for specialty care are even worse than primary care. At least for primary care, you can go to an urgent care after hours or weekends. There is no way to see a specialist outside of 8:00 to 4:00, not to mention it’s often a months long wait for an initial appointment.

    A lot of people (at least in my neck of the woods) think that your success is 80% your own effort and 20% who you know while your failure is 100% your fault. Only a high school education, homeless, food insecure, etc. are all the result of choices you made.

    This. Most people in the UMC/UC don’t understand or appreciate the advantages they have. There’s a local conservative radio host who is very fond of saying that “conservatives want equality in opportunity, while liberals want equality in outcomes.” Yet he doesn’t grasp the concept that just because everyone can get a free public education doesn’t mean that everyone has an equal opportunity.

  41. With insurance company evaluations of “physician outcomes based on patient outcomes/readmittance”, he’s blamed for all this.

    Even worse are the evaluations of patient satisfaction. ER providers get slammed because they won’t provide narcotics to obvious drug seekers. Hospitals focus more on amenities than medical care so they can get good HCAHP scores. It’s ridiculous.

  42. It just looks like a mini-bubble that is likely to fail. That real estate would be expensive to retrofit to another use – I would project most of the chains of them will be bankrupt in 3 years due to overexpansion.

  43. Denver Dad, we also don’t want to look very carefully at how much outside forces (government, etc.) can mitigate natural inequality. Adoption is the most extreme intervention possible in the life of a disadvantaged infant and when you compare the outcomes of biological and adopted siblings in adulthood, the statistical difference is still stark.

  44. What do you mean by that, WCE? Adopted children outcome versus biological siblings in their birth family or biological siblings in their adopted family?

  45. Families that include both biological and adoptive children seem to have much better outcomes for the biological children than the adoptive children for children adopted from the U.S. This is something that changes over time in such a way that I am convinced that genetics (vs. intrauterine environment) is the dominant role for children adopted as infants/toddlers. Children adopted from overseas who are adopted older are often traumatized by war or their experiences on the street, etc such that genetics is no longer the primary variable. Children adopted from China or South Korea seem to do better than children from Russia/eastern Europe/Americas, probably because of the characteristics of the mothers who put them up for adoption and the high quality foster care system in South Korea. I’m aware of minimal research on this; mostly anecdata from the adoptive families I know.

  46. “conservatives want equality in opportunity, while liberals want equality in outcomes.”

    Interestingly, Bill Clinton said when he was president that he was seeking the former.

  47. “After about 2 hrs of waiting, I realized: they don’t care how much pain I am in, because my injury is not life-threatening”

    I’m wondering if in this particular situation, an urgent care clinic wouldn’t have been a more appropriate choice than an ER, for multiple reasons.

  48. My perception is that much of Bill Clinton’s success was based on co-opting moderate R positions.

  49. I’m wondering if the free-standing ERs are required to take all patients, like hospital ERs.

    My understanding is that locally, the default destination for ambulances is the nearest ER that is not turning away patients. I believe that’s how FIL ended up at Kaiser even though he wasn’t a Kaiser patient. Is that the case elsewhere?

  50. “I like the idea of the annual meeting with your doctor in your own home. . . So it could require a shifting of doctors out of specialties and into general practice if we had the political will to implement here. ”

    Another way to implement something similar would be to have NPs or Physician Assistants handle those visits.

  51. “As a matter of resources, I don’t know if it’s better to care for babies born 24-28 weeks or let them die, as many countries (including parts of Europe, officially or unofficially) do, but such decisions dramatically affect healthcare costs and statistics.”

    What if care for such babies was an optional coverage? E.g., during open enrollment, you pick your insurance/healthcare provider, your plan, and at the same time decide if you want to pay extra for care for any babies you might have born before 28 weeks.

    I guess one obvious issue would be determination of actual gestation time. I wonder how they determine that in Europe. Perhaps it is, at least in part, a different cultural expectation there than here.

  52. All of the freestanding ER’s have to be capable of treating everything that comes in the door. Is it an efficient use of resources to increase the number of ER’s to reduce wait time to 30 minutes when many of these visits are not true emergencies and could have been covered by urgent care or a call from a doctor? It probably would be more efficient for the insurance company to hire a doctor to do after hour house calls than to have fully staffed and equipped ER’s so accessible that people think it is a viable alternative healthcare option. This would be a time that I think having some government input on the need for another freestanding ER would be valuable.

  53. “I was talking to a young, retired OB/GYN at church this week who retired in part because he didn’t like dealing with his disadvantaged patient population. They don’t shower regularly, they don’t follow instructions, they overuse drugs/alcohol and are eager to sue if anything goes wrong. With insurance company evaluations of “physician outcomes based on patient outcomes/readmittance”, he’s blamed for all this. He decided he was just done.”

    I’m wondering if working for an HMO would insulate him from many of these issues.

    He also sounds like a candidate to help staff a concierge practice. In the big picture, that would probably be better than him completely not practicing.

  54. “It probably would be more efficient for the insurance company to hire a doctor to do after hour house calls than to have fully staffed and equipped ER’s so accessible that people think it is a viable alternative healthcare option. ”

    I think that’s a point DD was trying to make.

    And I think the insurance companies ultimately can make or break these ERs by whether they continue to reimburse treatment they provide at ER rates.

    “That real estate would be expensive to retrofit to another use”

    One use that might be an inexpensive retrofit is urgent care clinic. Or perhaps the office of a small private practice.

  55. @ WCE – you say the “statistical difference is stark,” but then you say you are relying on anecdata. What do you mean? Are there actual studies on what you’ve asserted?

  56. I didn’t go to med school and don’t know anything about insurance but couldn’t the government be encouraging people to go into primary care and also increasing community health access by having people serve for a period of time in local community clinics? I am trying to work on projects in low income communities and “market forces” will result in accessible, affordable healthcare and grocery stores never setting up shop nearby. Even a city incentive to cover startup costs doesn’t bridge the gap.

  57. Mia, I believe there are government programs that will pay off student debt for MDs who practice in underserved areas for a certain period of time.

  58. I didn’t go to med school and don’t know anything about insurance but couldn’t the government be encouraging people to go into primary care and also increasing community health access by having people serve for a period of time in local community clinics?

    Tell ya what, how about you be assigned for work in a location that that you don’t want? There are lots of needs in local areas, surely society would be better off if you were required to provide your services for a period of time in some other area?

    If you aren’t willing to disrupt your life this way, why is it ok to suggest that government force others to disrupt their lives that way?

  59. Encouragement isn’t the same as forcing.

    An economist would tell you that you can get MDs to practice in less desirable locations by paying them more. One way the government could do this by increasing reimbursement rates in underserved areas.

  60. “It probably would be more efficient for the insurance company to hire a doctor to do after hour house calls than to have fully staffed and equipped ER’s so accessible that people think it is a viable alternative healthcare option. ”

    I think that’s a point DD was trying to make.

    See the link for Dispatch Health that I posted above. They will send an NP or PA to your house so you don’t have to go to the ER. All the major insurers have signed on because the cost is about 25-30% of an ER visit.

  61. An economist would tell you that you can get MDs to practice in less desirable locations by paying them more. One way the government could do this by increasing reimbursement rates in underserved areas.

    They are essentially doing this already with loan repayment programs. They have them for midlevels as well – I could have all my loans repaid if I was willing to work in a rural area. But as Cordelia said, I’m not willing to disrupt my life to do that.

  62. Lark, I’m relying on anecdata from my own observations (a few dozen over a few decades in churches I’ve attended) and comments provided by Holt to acquaintances considering domestic and international adoption. This is probably the best study from the Texas adoption study I’m aware of. It includes a few hundred respondents and the data is always decades out of date.

    Sample sizes are small, reasons for adoption change over time (the Korean War is long over, so the particular challenges of Korean adoptees are different than they were) and cases are variable, so it’s very hard to have good data.

    http://link.springer.com/article/10.1007%2Fs10519-007-9144-5

  63. “What if care for such babies was an extra coverage?”.

    And then what? No care for the baby, regardless of predicted outcome (which is actually very difficult for neonatologists to do)? Are we going to also have cancer riders and heart attack riders and car accident riders? Sorry if you pick wrong. You just die. If not, I am not sure why we would handle premature babies differently. Then are people, too. Better and more ethical to just have a cut-off (which they have now; perhaps we need to make it later than it currently is since these babies are so costly).

  64. Economist Greg Mankiw has written about adoption studies and government policy.

    How much income inequality is explained by varying parental resources?

    The bottom line: Even a highly successful policy intervention that neutralized the effects of differing parental incomes would reduce the gap between rich and poor by only about 2 percent.

    Biological siblings are much more alike in education and income outcomes than their adoptive siblings.  The reasons are multifactored, but genetic effects matter.

  65. Finn said
    “What if care for such babies was an optional coverage? E.g., during open enrollment, you pick your insurance/healthcare provider, your plan, and at the same time decide if you want to pay extra for care for any babies you might have born before 28 weeks.”

    Because most people are not going to choose it because they think it will never happen. Many of those very premature babies are born to teens who didn’t even plan on getting pregnant. And what happens when the mom didn’t choose the coverage? We let the baby die? Do you think evangelicals are going to get on board with that?? No, we will save the baby and let the mom go bankrupt because she didn’t buy the coverage.

    That is one of the problems with the extreme choice approach to insurance. Most people don’t know what to pick because they have no idea what might hit them. For example, people in their 20’s might choose a plan that strictly limits reimbursement for chemotherapy because they are young and young people don’t get cancer. And then, bang, they do.

    One of the ideas that Republicans are mulling over is the continuous coverage concept – that you can get preexisting conditions covered as long as you keep your coverage. But Republicans also want to allow bare bones plans aimed at young people. One of the things I don’t understand is how that won’t lead to a death spiral. Let’s say you are 23, and working as a Uber driver, so you pick the bare bones plan that does not have good coverage for complicated chronic conditions like diabetes. And then, sometime in your early 40’s, you develop type II diabetes. Now, you are going to want to switch to the better insurance that covers diabetes really well. I assume you are going to pay more for it – but it will be a LOT more because only people with issues like diabetes are buying that insurance and they cost a lot to insure. The premium increase won’t be gradual like it is today – it is likely to be very steep because only the sick have that kind of insurance. What will that person do now?

  66. I also read that article on the people in KY who didn’t believe Trump would repeal their coverage. There are some factors there that you guys may not know. One is that the Obamacare link was always played down because people in KY hated Obama so much, even back when he was elected. The governor feared people would not sign up if they thought Obama was behind the coverage. So they renamed it to KYnect, and set up a state run exchange, even though it was just Obamacare. Secondly, the current governor, Bevin, came in with a specific pledge to end KYnect, and they voted for him too. So I am not getting why they thought they were keeping their coverage.

    Most of the grousing in that article, and in other articles I have see that criticize Obamacare, is about the high deductibles. But I thought that was a key Republican idea – you know, skin in the game and all that. When the replace happens, the new plans are likely to not only be a lot more limited but also to be high deductible. What will these people say then?

    The other big Republican idea is that of high risk pools. Which just makes me slap my forehead in amazement. Don’t people ever look back at what worked and what didn’t? High risk pools were a total failure. The problem with them is that they are obscenely expensive to run, and no state was ever willing to put even a fraction of the needed money into the pool. Kentucky tried it around 2000, and managed to only ever enroll about 3000 people, because the premiums were so high, there were waiting periods to get coverage, and the coverage was very bad. This was the experience in state after state. One of the reasons I remember it so well was that I was working in the healthcare IT sector during the final death throes of the idea, so I remember all the discussion in healthcare policy circles.

  67. I can’t find the article, but one of the most interesting concepts I’ve found is that we let people buy insurance that covers only the most cost-effective x% of treatments. This means that people with less money have drug coverage but not coverage for drugs that are much more expensive for a marginal benefit. You’d need to have a list of covered services/treatments and reimbursement that was updated annually by company for this to work. Right now, medical services only have to show benefit to be approved- there is no linkage between cost and the percentage improvement. My brother in hip/knee R&D says we’ve already done at least 90% of what’s possible, and that more expensive joint replacement options are only slight improvements or for small, specific populations, e.g. young cancer survivors for whom a joint that lasts 40 years is a real benefit.

    This would mean that people with cheap insurance would probably get less cancer treatment, because any care above the cost threshold of, say, $20k/QALY, would not be covered. This is how healthcare is kept affordable in European countries with good coverage, but in Europe, the cost limits apply to everyone, not just working/middle class people who can’t afford top-of-the-line coverage.

  68. WCE said “his would mean that people with cheap insurance would probably get less cancer treatment, because any care above the cost threshold of, say, $20k/QALY, would not be covered. This is how healthcare is kept affordable in European countries with good coverage,

    This is really not true. France in particular has incredibly good coverage for cancer treatment. The kids in Europe on my ped cancer lists get treatment that is very similar to what they get here, and in fact, many of the top oncologists in this country collaborate on research with their European counterparts.

  69. I also think the concept of choosing the cheaper insurance that only covers the most effective treatments is beyond the brain cycles of most people. Very few people, in fact many doctors I have met, truly understand the idea of effectiveness in medical treatment. Obstetricians, in particular, have a terrible track record on this

  70. “but in Europe, the cost limits apply to everyone, not just working/middle class people who can’t afford top-of-the-line coverage.”

    No concierge medicine in Europe, or private physicians, or other medical services provided outside of what’s provided by the government?

  71. I can’t find the article, but one of the most interesting concepts I’ve found is that we let people buy insurance that covers only the most cost-effective x% of treatments.

    Doesn’t that presuppose the existence of a great untapped font of cognitive ability and executive function?

  72. “There is no incentive for docs to go into primary care because all the money is in the specialties.”

    During his last checkup, DS’ pediatrician (I assume pediatricians are PCPs) asked DS to consider becoming an MD, and in particular, a PCP, perhaps even a pediatrician. This was shortly after an article in the local paper mentioned that a local hospital is offering MDs $300k+ salaries, and when I mentioned that, he said that pediatricians like him don’t make that kind of money. He was vague, but my perception was high 100s.

    I think DS would make a great pediatrician (and would have a great shot at getting into the BS/MD program at flagship U), but he’s not interested in being a practicing MD.

  73. “Many of those very premature babies are born to teens who didn’t even plan on getting pregnant.” They are. And that group isn’t going to elect coverage. I have no idea what I would have chosen. My risk of having a 28 weeker, as an UMC 30-something with no known risks who received prenatal care from the start, was very low. And yet I did. Isn’t that kind of the point of insurance? To pool risks and pay out for low probability events for the unlucky winner of the risk?

  74. Finn, Germany and France are not single payer countries. They both use a public/private mix that varies in the details, and is pretty complex. The key ingredient in both countries, and indeed, in all of the many non-single payer countries, is that the base plans are highly regulated and provide decent coverage, the insurance companies are non-profits, and everyone has to have coverage. These are the very elements the Republicans want to get rid of, which just astounds me. Why not use what all the successful countries have in common? Why go try something that no one else does?

  75. Rhett, I don’t think it requires exceptional executive function. I think most people will choose the low-cost option and then complain about the fact that they don’t get pancreaticicoduodenectomies or their preferred ADHD medication covered after coverage is denied. People who aren’t dead yet can make a different, more expensive choice in the future.

    Mooshi, I don’t think France is a great baseline for “European” coverage, though I suspect you’re right and France offers great medical care. Scandinavia, Germany and France are more like the New England/Mid Atlantic states in the U.S. Mississippi and New Mexico are like Macedonia and Romania.

  76. Rhett, no, Born Alive Infants Act makes care a nightmare. Once a baby is born, parents DO NOT have the right to decline care, even if the baby has no brain.

  77. These are the very elements the Republicans want to get rid of, which just astounds me.

    That’s not even really true. They say a lot of things and then you look at their plan and there are hardly any changes. I think Obamacare opposition polled well so they hammered that point, but they know full well that any solution they end up passing is going to look almost identical to Obamacare.

  78. Rhett – at the hospital where my child was, parents decide whether the doctors should take heroic measures at 23 and 24 weeks. At 25 weeks, the doctors just do it unless there is clear evidence that the baby won’t survive.

  79. “And then what?”

    Level of care would either follow the European model, or the American model, depending on whether the option was chosen.

  80. Which plan? The Republicans have several
    Price’s plan pushes health savings accounts, which are usually paired with high deductible plans, and tax credits to buy insurance. I don’t see anything about subsidies. He wants to have state run high risk pools for the uninsured with medical needs. If you keep continous coverage then preexisting conditions are covered, but I am not sure if you could be subject to price increases.

    Ryan’s plan pushes health savings accounts, and uses tax credits to buy insurance. As far as I can tell from his website, which isn’t written in the most transparent way, he wants states to establish high risk pools. I can’t figure out what his mechanism is for dealing with pre existing conditions, though he says his plan will. Is it continuous coverage or high risk pools?

    Republicans also want to offer more bare bones plans (usually written as permitting greater choice) which again is very different from the Western European idea of highly regulated plans. And what do you think the old chestnut of allowing people to purchase plans across state lines will do?

    I think these plans are very different from Obamacare

  81. “Isn’t that kind of the point of insurance? To pool risks and pay out for low probability events for the unlucky winner of the risk?”

    And in some cases insurance is not mandatory. E.g., if you own a paid off home, there’s probably no mandate for you to have homeowner’s insurance.

    But my question wasn’t a proposal, it was a muse based on the apparently different standard of care for preemies in Europe relative to here.

    Another muse– if it’s true that in Europe they don’t provide care to pre-28 week preemies, why aren’t pro-lifers having a fit over that?

  82. “Price’s plan pushes health savings accounts, which are usually paired with high deductible plans, and tax credits to buy insurance. I don’t see anything about subsidies. ”

    Aren’t tax credits a form of subsidy?

  83. They provide care in Europe. Many countries just don’t count those babies born then as part of the mortality rates for neonates.

  84. I think in the Republican plans, the tax credits are not based on income and are smaller.

  85. Here is a summary of the Price plan from that article
    “t has some of the familiar provisions of the other proposals we’ve run through so far: the return of preexisting conditions for those who don’t keep continuous coverage, age-based tax credits, and a limit on the tax exclusion for employer-sponsored coverage.

    Price’s bill arguably does less to protect sick people than Better Way does. It includes very little funding for the high-risk pools: $3 billion, compared with Better Way’s $25 billion. Its limit on the employer-sponsored tax exclusion is significantly lower than other proposals ($8,000 for an individual, compared with Patient CARE’s $12,000 cap). Both of these differences would make Price’s bill less expensive for the government, and might be alluring to legislators as they begin the budgetary scoring process.”

  86. Finn, I think there’s a difference between what European countries officially provide, especially in the poorer countries, and what care disadvantaged people actually receive. I suspect room is more often found in the NICU’s for UMC babies than poor babies. I don’t know if anyone has studied whether, say, Romani babies have real access to NICU care in eastern Europe. I think NICU funding is different in the U.S. and pretty much all NICU’s take Medicaid for poor babies.

  87. “There are a couple of simple things we can do to address the shortage of primary care doctors. The easiest is to increase the number of residency spots.”

    I was talking to an MD friend of this recently, and he told me that residency spots are very expensive, and more generally, educating a physician is very expensive, and the med student only picks up a portion of the tab. In order of magnitude numbers, he estimated educating a physician to the point of being ready to practice to cost ~$1M, with the student picking up several $100k of that.

    This led to a discussion of the number of moms we know who are non-practicing MDs, and how it does not seem to have been in society’s best interest to educate them instead of other candidates who would have become practicing MDs.

  88. BTW, requiring continuous coverage to be able to get insurance with a pre-existing condition was pretty much how the employer-based market worked prior to Obamacare. It didn’t work that well because for a lot of people, when they get really sick, they quit their job and lose their insurance. If they can’t afford to maintain COBRA coverage, then they have a gap and become uninsurable. That was a common problem in the pre-Obamacare days.

  89. I said we should be looking at successful practices in countries comparable to us, wealthy countries. That doesn’t mean all of Europe, but it does mean Japan, and perhaps Singapore. Looking at Romania to see what they do is like looking at China or Cuba or Brazil to see what they do. We shouldn’t copy the UNSUCCESSFUL countries.

  90. “young, working class people can’t afford to further subsidize healthcare for older people.”

    It seems that trying to get young, healthy people to subsidize healthcare for older people would exacerbate failure to launch issues.

  91. “young, working class people can’t afford to further subsidize healthcare for older people.”

    How are they doing it in Germany or Switzerland?

  92. And along those lines, I would guess that they are going to be subsidizing no matter what, because if mom loses her insurance and can’t afford a plan, it will be up to those kids to subsidize her.

  93. Some states had high risk pools before the ACA. I worked with several, and they were disasters. Frequently they were oversubscribed, so you couldn’t get in or you had to wait several years to get coverage. Premiums were astronomical, and there were no subsidies. Coverage was in some states very bare bones, and had relatively low lifetime maximums.
    I haven’t looked at current proposals, but unless they have something completely different in mind, it won’t work.

  94. is that we let people buy insurance that covers only the most cost-effective x% of treatments.

    Insurance companies, and particularly Medicare, are approaching it from the other way. They’re moving towards a “we’ll only pay for the treatment/drug/device with highest efficacy record.”

    Insurance companies with their big data are in a great position to evaluate these kinds of outcomes.

  95. “perhaps Singapore.”

    One thing Singapore has in common with Cuba is an authoritarian government, and a long history of being let by a single dictator, so if we’re going to look to Singapore, we may as well look at Cuba.

    And IMO it makes sense to look at both of them, just keeping in mind the societal differences that means what may work in one place won’t work in another, and try to pick out what can work here.

    E.g., I’m thinking it might make sense for urgent care clinics, often staffed by NPs or PAs, to also offer preventive care, e.g., the regular checkups. The extended hours would address, at least in part, the accessibility issue brought up by anon, and would be kinda sorta like the regular visits in Cuba.

  96. If they can’t afford to maintain COBRA coverage, then they have a gap and become uninsurable.

    Obviously they should have adjusted their 18 month cash emergency fund to include the cost of COBRA. I kid but that is how some wonks think.

  97. Finn, I said “maybe Singapore”.
    And yeah, these countries are different from us, but Western Europe and Japan also share a lot with us – democratic, wealthy countries. And there is a lot of commonality to how their healthcare systems work. Why don’t we want to take a look? Why charge after something that no other country with a successful system does?

  98. “because if mom loses her insurance and can’t afford a plan, it will be up to those kids to subsidize her.”

    Which kids are “those kids?”

    If they are her kids, my guess is that it’s fairly likely that they won’t have the means to subsidize her, and in fact they may not have any coverage themselves.

  99. “Why charge after something that no other country with a successful system does?”

    Perhaps because they are based on principles that many find unacceptable?

  100. Also, wouldn’t the ‘gap’ apply to anyone who had a gap of, say, a month between jobs when they are 25 and didn’t elect COBRA for that month because you can do it retroactively and they didn’t want to pay for it unless they got sick?

  101. Here is what I don’t understand: The difference between Obamacare and Patient CARE are so minor, yet so many voters were so incenced. What was their actual opposition to Obamacare?

  102. Woo hoo! DS just got an affirmative response to his EA application.

    Now that he has a safety, we can have a relatively stress-free break, and it will save us several hundred $$ in app fees we won’t need to pay.

    His finals start tomorrow, so we will wait until after finals to celebrate.

    HM, DS is trying to be low-key about his selection process, so please keep it under your hat.

  103. Totally agree LfB as usual. My husband went to the orthopedist recently because he had a problem with his shoulder. Thought maybe rotator cuff. Turns out just a muscle strain so PCP would have been fine but the prospect that he might miss 2 hrs. work for a PCP only to be referred to the Specialist for a total 4 hour loss of productivity was worth the expense. I think there is a minimum standard that should be available but there will always be something extra for those willing to pay more. Like everyone is entitled to a Camry but some will buy a Cadillac.

  104. Rhett, where are you getting this “The difference between Obamacare and Patient CARE are so minor,”?
    Prexisting condition coverage only allowed with continuous coverage, vs automatic preexisting condition coverage?
    Dumping people into high risk pools vs automatic preexisting condition coverage?

    Those are BIG differences

  105. Oh, I see, Rhett limited his comparison to Hatch’s plan. But that is the least likely one to pass because it has what looks like essentially a mandate “But the CARE Act gets a bit more aggressive about making sure people actually enroll in plans. It envisions the government picking a “default” health plan that those who don’t pick anything would automatically be enrolled into.”

    And it still uses continuous coverage as the measure for getting insurance with a preexisting condition

  106. People like Obamacare in principle. The main complaints are the cost and the fact that Obama was involved. Not sure what to say about the second part, but good healthcare is expensive any way you slice it. Had I been in charge I would have made the penalties much higher for not complying and increased the subsidies (both the amounts for those who qualify and given subsidies to higher income people). But that isn’t politically palatable.

  107. “People like Obamacare in principle.”

    I’m not sure about the part about getting healthy young people, many of whom are having difficulty launching, subsidize older folks, who’ve had time to accumulate assets, especially given the demographics.

  108. “And one freestanding ER where I worked for a while, we saw a high number of patients from a certain large company that was known for its generous insurance plan.” I used to work at a place with Kaiser and you could get a same day visit for $5 – boy did people abuse that. They would go in for a cold or the smallest ache and pain. There is some sweet spot where it is costly enough that people will think before going but not so costly that people will not go until it is untenable. It is a hard place to find.

    @qqq – My son was in Cuba this summer for 10 days. They went all over the place. Granted it was a high school band but there were no minders. He had a great time and would like to go back!

    In my opinion we need better access to mid level care. You don’t need a PCP for strep, or pink eye or bronchitis or a sprained ankle. If we could boost the number of NPs and PAs and implement some effective triage system that would leave the difficult cases for the PCPs and move the others through. I use the Minute Clinics like that because it is hard to get into my PCP.

  109. Finn – agreed. I do think many of them like the ability to stay on their parents insurance for an extended period of time. That wasn’t available when I was in law school and it caused some problems. As a whole, I think most people prefer to have Obamacare as an option and like the pre-existing condition part, the 26 year old part, the elimination of the lifetime cap part and the expansion of Medicaid if their state did that. Nothing is perfect.

  110. The main complaints are the cost

    90% of Americans have Medicare, Medicaid or employer based insurance. Of the those on Obamacare 80% have a subsidized policy. Most of those in favor of the repeal aren’t those who were effected.

  111. Eliminating lifetime caps was huge for people with serioius medical needs. I saw several families exceed their million dollar caps in one to two years of treatment for their kids cancer. Also, back in those days, plans sold on the open market were allowed to have very low caps, caps that you could exceed just with a single heart attack. I do not see the Republicans mentioning lifetime caps, and since they want less regulation on plans, we could easily go back to those days.

    Basically, I see all the Republican plans as basically taking us back to the way it was before Obamacare, but with some level of tax credits if you buy on the open market.

  112. Finn, congrats…that is great news, and must be such a relief after all of this time.

    We have friends that are struggling with health insurance in several states. They are self employed, and they can afford insurance. The problem seems to be that plans close or get dropped every year. It seems like there are fewer options out there even for people that can afford it, or understand how to research options. They are living in CA, CO and FL.

    It has been a real struggle for my friends in CA because they have a child with a chronic disease and she has very high medical bills. They can’t plan for everything because she often picks up what would be a minor stomach virus or cold for any other child, and ends up very sick. She has been admitted to the hospital twice this year as a result of her body not being able to fight off a virus. Their insurance doesn’t cover a lot of stuff and they spend A LOT of time on the phone with their insurance company, doctors and hospital billing office to resolve some of the problems.

  113. who’ve had time to accumulate assets

    The nonpartisan RAND Corporation has modeled the effect of this switch. It found that premiums for a 24-year-old would decline from $2,800 to $2,100. But premiums for a 64-year-old would rise from $8,500 to $10,600.

    Obviously, in order to maiantain continuous coverage you should increase your retirement contributions to cover you if get laid off and 57 and age discrimination renders you unemployable. You should also increase the balance of you 18 month emergency fund to cover you if you need COBRA when you get laid off at 34.

    The reality is the median American doesn’t even have (a my grandmother would say) a pot to piss in.

  114. Kate,

    I agree. That’s why I think Trump could work out well in the end as many will gladly support proposals by Trump, that if Obama proposed them, they would have hysterically opposed.

  115. I’m not sure about the part about getting healthy young people, many of whom are having difficulty launching, subsidize older folks, who’ve had time to accumulate assets, especially given the demographics.

    The fundamental issue is that health insurance doesn’t work if the healthy, low-risk people aren’t in the pool.

  116. “In my opinion we need better access to mid level care. You don’t need a PCP for strep, or pink eye or bronchitis or a sprained ankle. If we could boost the number of NPs and PAs and implement some effective triage system that would leave the difficult cases for the PCPs and move the others through.”

    When I was with Kaiser, this is the type of care I had. They had a 24 hour phone consultation service staffed by nurses, and also provided us with a simplified medical reference, to address some of the more standard issues and often obviate the need to see someone in person.

    When I did go in for my annual checkups, I usually saw a the same NP. I also had a PCP, but didn’t usually see him for checkups. I liked this team approach for the continuity it provided; when my PCP moved up to head a new department, having the same NP provided that continuity despite getting a new PCP.

    “I use the Minute Clinics like that because it is hard to get into my PCP.”

    Are they very small?

  117. Rhett – maybe. Although everything he touches seems to turn out bad. Look at his infrastructure plan. Could have been great. Instead is terrible. And if he lets the Congressional Republicans get their way, Obamacare is done.

  118. I’m not sure about the part about getting healthy young people, many of whom are having difficulty launching, subsidize older folks, who’ve had time to accumulate assets, especially given the demographics

    That doesn’t change the math. If you have to pay $200 extra in health insurance when you’re 27 or put an extra $200 in your 401k to cover COBRA when you’re 57, the numbers remain the same.

  119. Denver Dad, I agree that healthy, low risk people should be in the pool, but ACA ignored the actuarial reality of cost differences between groups of people in support of the laudable goal of avoiding age discrimination. The 3x cost difference mandate by age was not based in actuarial data. Government cannot ignore real costs by passing laws- unintended consequences result.

  120. Lauren said “Their insurance doesn’t cover a lot of stuff and they spend A LOT of time on the phone with their insurance company, doctors and hospital billing office to resolve some of the problems.”

    This pretty much describes us when my kid was in treatment, which was pre-Obamacare. We had employer-based insurance.

  121. WCE,

    I assume your plan would be a 5x gap between young and old but the same subsidy structure?

  122. “ACA ignored the actuarial reality of cost differences between groups of people in support of the laudable goal of avoiding age discrimination.”
    Other countries handle this by using taxes to pay for it, which means you are basically paying based on income rather than age or health. We were also doing that by using expanded Medicaid and subsidies, but didn’t go far enough. Payment based on income, I think, is preferable.

  123. I hate Telecharge. I don’t understand how they can charge $11 per ticket and another handling charge of $3 even though they don’t mail the tickets unless you pay another $4.25.
    It feels like such a scam every time that I want to buy tickets, and i can’t make it to the box office in person.

  124. Congratulations to you and your family, Finn, since I know it’s a relief for everyone. When does he hear from his first choice? Not til later in the spring?

  125. I agree with Mooshi that paying based on income (via regular taxes) rather than age or health is the best approach.The problem with Germany’s system is its applicability to a population with a high percentage of retirees; Germany will probably figure out how to solve that problem before we do. I think the federal government (not states) should subsidize the most-expensive patients using income tax dollars (and the necessary number will be BIG, probably requiring tax increases) and that patients in that high cost pool will be subject to cost restraints similar to those in VA/Medicaid/Medicare. It is not fiscally sustainable to do everything technically possible for all people.

  126. It is not fiscally sustainable to do everything technically possible for all people.

    We’re not doing that now.

  127. RMS, our systems are set up to produce more expensive medical technologies without much thought as to whether they are more worthwhile than other goods, such as public education and heat subsidies for the poor.

    No one has a good system for figuring out who we should let suffer and/or die.

  128. Thanks, RMS. I’m glad to hear you are all relieved.

    I don’t know if he has a strong first choice; he’s never really articulated one to us. Perhaps he was intentionally hedging to avoid disappointment, since the schools he liked all have fairly low acceptance rates. But there are 2 or three that he definitely likes and check all of the boxes most important to him, and I’m sure he would be happy going to any of them.

    I think all of the other schools at which he’s applying typically announce regular decisions in March. He didn’t apply at MIT, but they’re famous for their 3/14 announcement date.

    I think the next decision point will be in January, when a couple of the schools will contact students they’ve identified as candidates for their full tuition scholarships. We’re assuming that hearing from them for that would imply acceptance.

  129. Thanks, RMS. I’m glad to hear you are all relieved.

    was in response to:

    Congratulations to you and your family, Finn, since I know it’s a relief for everyone.

    1. The universe of discourse was completely clear from my sentence. “Everyone” referred to everyone in Finn’s family. That wasn’t a grammatical error. It wasn’t my error at all. The error was yours.

    2. Since we’ve (universe of discourse: The Totebag readers) been listening to you obsess for two years now, then yes, it’s a relief for us (universe of discourse: The Totebag readers).

    Jesus H. Christ. Get a new hobby.

  130. “our systems are set up to produce more expensive medical technologies without much thought as to whether they are more worthwhile than other goods, such as public education and heat subsidies for the poor.”

    A single payer system which doesn’t prevent private providers might do this to a small extent, with very wealthy people spending a lot to develop treatments important to them.

    “No one has a good system for figuring out who we should let suffer and/or die.”

    We should try to mitigate suffering across the board. Who dies is tougher.

  131. “I’m wondering if in this particular situation, an urgent care clinic wouldn’t have been a more appropriate choice than an ER, for multiple reasons.”

    Just to clarify, I would have far preferred to go to urgent care. But at 11 pm on a Sunday night, the ER was the only game in town.

  132. RMS, I was referring to line item 2.

    BTW, I have DD, so it’ll be a few years before I get a new hobby.

  133. The new hobby referred to picking on grammar and spelling. Obviously you have to obsess about your children. It’s What We Do (universe of discourse: Totebag readers).

  134. A single payer system which doesn’t prevent private providers might do this to a small extent, with very wealthy people spending a lot to develop treatments important to them.

    Does that ever happen? You certainly have wealthy people funding things like HHMI or the Picower Institute that do foundational and translational research, but it’s unheard of AFAIK for treatments to be developed because rich people will pay out of pocket for them.

  135. BTW RMS, I really did appreciate your expression of relief on behalf of the Totebag reader universe of discourse, as an expression of empathy and/or sympathy.

  136. Wasn’t’ she?

    I’m guessing not. She was looking for pain relief, however they would be able to provide that.

  137. I haven’t read all the comments, but saw discussion at the top about docs being placed for their practices. In some parts of Appalachia, many if not most physicians are from other countries, and received their med school here in exchange for working where they were most needed.

    Anyone looking for a place to make end of year charitable donations, here’s one suggestion: https://www.razoo.com/us/story/Cdij6g

  138. “In some parts of Appalachia, many if not most physicians are from other countries”

    The MD friend I was discussing things with mentioned that one reason many rural physicians are foreign is that while their pay is low by US MD standards, it’s very good by the standards of their countries of origin.

    Considering the shortage of physicians we have, particularly for such areas, and the cost of educating them here, importing physicians would seem to be a logical way to address, at least in part, our physician shortage.

  139. Considering the shortage of physicians we have, particularly for such areas, and the cost of educating them here, importing physicians would seem to be a logical way to address, at least in part, our physician shortage.

    I agree. Unfortunately there are high barriers to entry for foreign physicians. A QMAP (a CNA certified to pass medications) in one of the assisted livings I go to was a doctor in his country of origin (I think an African country, I’ve never asked him). He wants to go to nursing school and then become an NP because there’s no way for him to work as a doctor here. It would be great if there was some way we could certify people like him to work here.

  140. DD – I’ve always been surprised that some medical school hasn’t come up with a program that could fast track doctors from other countries while ensuring they are trained to the appropriate standard.

  141. In the home country, students enter medical school after the 12th grade. There is no doing four years of undergrad plus med school. The training time is much shorter. What this does is makes it cheaper overall to train doctors. It also puts a burden on the students in that they have to decide on a career path at an early age and are essentially locked in.

  142. Most people are aware of America’s looming physician shortage, but the shortage of residency slots for medical school graduates has received less attention.

    In order to practice medicine in this country, graduates of allopathic (MD) and osteopathic (DO) medical schools must complete a residency training program. In recent years the number of MD and DO graduates has increased by more than 23 percent in an effort by schools to address the country’s growing physician shortage, which the American Association of Medical Colleges estimates will approach 90,000 too few physicians by 2025.

    While the number of medical school graduates is increasing, the number of residency training positions has not kept pace. If this imbalance is not addressed, the number of American MD and DO graduates will exceed the number of first-year residency positions, which by some estimates could occur as soon as 2017. When this happens, young physicians-who dedicated years to the pursuit of a medical education and incurred significant debt doing so-will not be able to practice medicine, and the physician shortage will persist.
    Part of the problem stems from the funding mechanism for Graduate Medical Education (GME). Medicare covers the majority of the cost teaching hospitals spend on training medical residents, but the Balanced Budget Act of 1997 capped the number of residency slots the federal government would fund. The shortfall-what is not covered by the Federal government-is paid for by the hospitals where residents train. While it is possible to increase the number of residents they train, to do so, hospitals must fund the entire cost of those training positions.

    Though patient care has shifted its emphasis to wellness and prevention, the current reimbursement system has not yet caught up. It is still based on the number of procedures performed, incentivizing hospitals to fund additional residencies in revenue-producing specialties instead of primary care.

    Adding to the problem, are for-profit schools that pay hospitals for medical student residency training spots-an incentive for some cash-strapped hospitals-something that is a growing concern among medical school deans. Residency slots that are taken by trainees from non-accredited schools reduce the number of slots available to trainees from accredited allopathic and osteopathic schools.

    Some of these non-accredited for-profit schools train as many as 1000 students a year without clinical facilities or full time faculty. According to a 2013 Bloomberg Markets investigation, many students who attend these schools incur tremendous debt and fail to complete the programs; many of those who complete the programs are unable to find a residency.

    The shortage of residency slots is also affecting graduates of accredited programs. Last year, more than 500 graduates from US allopathic medical schools were unable to obtain a residency training position. As more students graduate from medical school in the coming years, this number will only increase.

    We need to find ways to address the shortfall. There are several solutions being considered.

    The Foreign Medical School Accountability Fairness Act, a bi-partisan bill from the House and the Senate that would protect taxpayers and students, eliminates an exemption that entitles certain foreign medical schools to US Department of Education Title IV funding without meeting minimum requirements. The bill would ensure that 60 percent of enrollees in medical schools outside the US and Canada must be non-US citizens or permanent residents and have at least a 75 percent pass rate on the US Medical Licensing Exam.

    Other pending legislation includes the Training Tomorrow’s Doctors Today Act, which would add 15,000 new residency training positions over the next five years; and the Resident Physicians Shortage Reduction Act of 2015, which aims to protect against the rapid shortfall of primary care physicians.

    The Affordable Care Act’s $230 million Teaching Health Center Graduate Medical Education Program is designed to train primary care physicians mostly in non-hospital settings, which is exactly where the majority of primary medicine is practiced. Moreover, many of these new training programs serve underserved communities. These residency programs do not rely on Medicare funding, but must be self-supporting by 2017.

  143. I am presumably a high bandwidth individual, and very sensitive to the need for health insurance. After I took the early retirement package from Big Employer, I got insurance from another employer, from whom I was eventually laid off in the recession. Then I went on DH’s retiree insurance, midyear, but since he is on Medicare I had the spouse policy. He only has dental. Apparently they did an audit and he had to be on their Medicare supplement for me to qualify for the spouse policy. We got some vague notice about the audit in the pile of routine benefits year end mailings and did not comprehend that they were going to cancel my coverage, and they took the premiums out of his retirement check, so I wasn’t aware that the deduction had stopped in January. (DH is not a detail man). So when I went to refill a prescription in March of the next year I found out I had had no health insurance for 75 days. If I had not been living under Romneycare, I would have been totally out of luck. To get onto the retiree group insurance, very expensive, at the Bigger Company that swallowed mine required, you guess it, proof of continuous coverage since retirement. NO gaps. And DH’s employer was not able provide the certificate of coverage for my 8 mos on their policy in a timely fashion so that I could retroactively deal with the missing 75 days, when luckily nothing had happened.

    Many consumers of Romney/Obamacare are over 50s, including the younger wives of men who are on Medicare or who are self employed. Such families may also still have dependents. There is almost no one who gets to 50 without having some recorded encounter with the medical system that would count as a pre existing condition.

  144. Late to the party, but just read through yesterday’s thread. Congrats to all the Totebag kids – lots of good news here!

    NoB, my boss had her appendix out a few weeks ago, requring her to miss a business trip the next morning, but she was up and around, but working from home, pretty quickly. I think she couldn’t carry anything heavy for a couple of weeks, but no major restrictions. Hope it’s a quick recovery for you.

  145. Doesn’t the National Health System (U.K.) import many of its doctors and nurses from India? I thought that’s what made it work.

  146. There is a path for foreign grads to become doctors, and it is long and expensive (for both the US government and for the foreign practitioner). Once the MD passes our basic exams (three full day tests, USMLE I, II, and III – usually taken over 2-4 years for American trains docs), they apply to a residency slot. We require that all practicing docs do at least 1 year (though in reality it is 3) of residency to have an unrestricted license. The choke point is acceptance to a residency – as noted by the anon above, it is becoming increasingly more difficult to get into any residency.

    In the US, we have historically imported a lot of nurses from the Philippines, but I’m not sure that is currently true.

  147. “In the US, we have historically imported a lot of nurses from the Philippines, but I’m not sure that is currently true.”

    A lot of the local Filipino kids born and raised here also become nurses.

  148. I’m wondering if the military is an option for someone with an MD degree who wasn’t able to land a residency.

  149. I know of a doctors kid who did his medical training in a school in the Carribean. The father already had a practice in family medicine and the son just followed. I had read that the Carribean medical schools weren’t as good.

  150. “I hate Telecharge. I don’t understand how they can charge $11 per ticket and another handling charge of $3 even though they don’t mail the tickets unless you pay another $4.25.
    It feels like such a scam every time that I want to buy tickets, and i can’t make it to the box office in person.”

    We were going to buy five tickets to the Rockettes this weekend, but DW and I both thought that the prices and fees, especially for five people, were priced beyond a sane level. Their tickets have been selling at TKTS lately, so we’re going to roll the dice and try that option. If they’re not available, we know the kids would like to see Phantom (they like the movie version), or something like that. Regular pricing is past the point where we say “E-nough!”

  151. “Laura, did they treat you as “drug-seeking”?”

    You know, I expected them to, but they didn’t. Maybe because DH was with me. Maybe because I was so obviously barely able to move (I was doing that frozen back don’t-make-me-twist-or-bend crab-walk). Maybe because I didn’t report a history of taking pain meds. Maybe because I’m an inoffensive-looking middle-aged UMC white lady. And maybe because the problem was rather obvious when it finally presented itself — I puzzled the heck out of the doc, who kept pushing spots and asking me if it hurt there, and I kept saying, no, no, no, and after a while she did start to give me a look; and then she said “let me try one more thing” and squeezed my rib cage, and I hit the roof, and the meds appeared instantly.

    The irony is I don’t even like pain meds — they hit me like a ton of bricks and make me feel loopy and out of control. We have several partial prescriptions of oxy and Percocet at home, because we take as few as we can to get through whatever it is; I guess I could have just taken some of that and hoped it took care of it and avoided the whole ER thing, but I was scared because it hurt to breathe, and I wanted to make sure I didn’t somehow do real damage. What I reallyreallyreally wanted was steroids. So I was very happy when that and a massive shot of anti-inflammatories took me down off the cliff and I never needed to resort to the oxy.

  152. “I’m wondering if the military is an option for someone with an MD degree who wasn’t able to land a residency.”

    There are programs where the military will put you through med school in return for something like 4-6 years service. This is something DD is interested in — since she wants to be an ER doc, she thinks it would be a path to getting good experience. Me, I’m not particularly fond of the idea that the kind of experience she wants to get would require her to serve in a war zone, but I’d be proud if she wanted to serve and would basically just hold my breath — and my tongue — for as long as she was over wherever. Our recurring argument is that she wants to go Army, and I keep pointing her to the Air Force (where my grandfathers served) or Navy (where my stepdad taught). :-)

    Of course, she also wants to be a chef and a biomedical engineer, so I’m not following this particular rabbit trail too far anyway.

  153. Milo, if TKTS doesn’t work, then you might want to try the box office. There are no service fees, but there are a few discounts available for certain shows. If you happen to bank with Chase, the box office will also help you find discounted shows/seats that are available for each show. I don’t think the early morning shows sell out so there are usually some discounts available.

  154. Thanks, I’ll remember that.

    I was about to say that my HSA is through Chase Bank, but no, we switched vendors.

  155. LfB – the military is an option. One parent in my kid’s school followed that path. He is an orthopedic surgeon. He avoided the loans but had to do the service requirements. From what I gathered from his wife, the no loans part was definitely worth the service commitment.

  156. If you want to be a military doctor, don’t go to one of the Academies. The number of available medical school slots directly from the Academies is typically limited to about 15. They do this because they’re spending a lot more $ on each student than an ROTC graduate costs, and, barring some medical condition that develops over those four years, they want a line officer for that price, not a physician.

  157. Milo – I thought of you as the Army vs. Navy game was on. My kids watched fascinated by the uniforms of the cadets. Those blue capes looked impressive.

  158. Foreign grads do have a pathway in most states. The typical problem is proving their medical training is equivalent to US medical training. Many of the Carribean medical schools do not advise their students well and as a result, they do not meet the licensing requirements without remediation (which of course comes at a cost). Most states have a list of foreign schools they have already vetted for equivalence, but schools tend to get on that list only after that state has had several applicants.

    In some states, tort reform has pushed the burden for patient protection to the licensing process and those states have higher requirements for entry.

  159. Congrats Finn!

    Only have a HS junior, but we have basically been told that if you apply for EA, you are expected to take that slot and withdraw all other apps. Am I missing something?

  160. Thanks to the anon’s for all of the helpful information. Very interesting.

    Cordelia – if I had $200,000+ of student loans, I would seriously think about it. Just like we encourage college grads to engage in things like TFA or Americorps, there are people who are interested in serving in ways that match their skill set.

    LFB – read an article a couple months back on ER docs and nurses in cities like Miami and Chicago that have a lot of gun violence in their level I trauma centers. Most of them had suffered from PTSD and the one doc who had been in the army said he saw worse things in Miami than he saw on the battlefield.

  161. Austin –
    EARLY DECISION is the path that’s typically what you say. It’s the kid’s #1 school and if accepted s/he will withdraw applications to all other schools.

    A (somewhat large) step down from that is EARLY ACTION, which is a school-specific thing and it usually means the kid applies ‘early’ and will get a speedier review and decision than the regular process. The schools like it because, presumably, the better qualified, highly interested, fairly decisive kids jump in to this process. The kids (e.g. my kid) like it because there’s no commitment to attend but acceptances take some (a lot) of the pressure off so the rest of senior year can just be classes + extracurrics. Some schools have EA1 and EA2 (e.g. Nov 15 and Dec 15), which I don’t really see the point of but maybe by posting dates like that they get chunks of applications vs one big pile at the….

    REGULAR DECISION date, which is the latest point in theory they will accept an application for fall admission.

  162. @Milo — thanks for the advice, hadn’t realized that. She is looking at the “regular college then military for med school” path, but I have harbored a secret hope she’d be interested in the AFA, so I’d have more excuses to go visit. :-)

    Of course, I’m also not convinced she will actually want to sign up for all those extra years of study when it comes right down to it — she just doesn’t enjoy the academics like I did and is impatient to go do stuff. So an academy that actually teaches useful skills and provides a career path immediately upon graduation might be more appealing to her in the end, even if she doesn’t think so now. Assuming she could get in, of course, and make it through, which is nowhere near a given.

  163. “I thought of you as the Army vs. Navy game was on. My kids watched fascinated by the uniforms of the cadets. Those blue capes looked impressive.”

    I can’t post this on FB, but I was halfway rooting for Army. They deserved a win after 15 years, and certainly if we can only bring our third-string quarterback. And it’s such an amazing game to attend in person, even for someone like me who has almost no interest in watching other people play sports. As my Dad phrased it, it’s nice to know that the Army-Navy game is still relevant.

    I don’t know about West Point’s capes, but I always remember how the Navy’s black wool overcoat was amazing that a piece of clothing could simultaneously be so heavy on your shoulders and neck, yet so useless at keeping out the cold. And those little white scarves are a joke.

    The year after I graduated, we went to Navy-Notre Dame on a really cold day, and I remember thinking that wearing corduroys, a fleece, and a North Face coat was the ultimate in game-day luxury. But it doesn’t look as sharp.

  164. Agree with previous poster that states often will encourage doctors to practice in rurual areas in exchange for reduced student debt. This just seems to extend the time before they settle down in that you often are taking a residency slot where it is offered not where you want to go. But, for the community this can mean they never have a doctor for very long. Changing that to a NP or PA may not make that much difference. If the practictioner is young and has/wants children, but doesn’t want to raise them in that rurual area, then they won’t stay if they can go elsewhere.

    My dad lived in the rurual part of another state at one point back in the 70s and they had a grouping of small towns over about a 100 mile radius that shared many things on a rotating basis including clergy and healthcare providers. In his town population < 200, one physical church building served 3 denominations – the largest congregation had a service every other week, and the smaller two had a service once a month on the "off weeks". In the same way, they "regional" medical center sent a doctor and nurse to the school once every two weeks and anyone in town could make an appointment or drop-in. Otherwise, you had to travel about 60 miles to that regional center.

  165. A friend did the military medical route. He went to Berkeley for undergrad, then worked as a software engineer for a few years, then decided he wanted to be a doctor. His dad was career Air Force so the military seemed pretty natural to him. So he joined the Army and they paid for medical school in Chicago. I think he spent more than four or five years in the service, though. He was mostly at Walter Reed (and when those awful stories about Walter Reed came out a few years ago, I really wanted to contact him and ask about them!). Now he’s an endocrinologist in private practice in northern Virginia.

  166. I was the anon at 7:36 because my phone didn’t pick up my name for some reason. I’ve also been able to show my AAA card at the box office to get discounted tickets with no fees. TKTS might work this weekend too because the weather looks nasty for Saturday so last minute people (like me) might skip a day in the city. We were supposed to take DD in to see some holiday stuff, but we will probably wait for a nicer day.

  167. “she also wants to be a chef and a biomedical engineer”

    Biomed engineering can be a good undergrad major before med school.

  168. EARLY DECISION is the path that’s typically what you say. It’s the kid’s #1 school and if accepted s/he will withdraw applications to all other schools.

    How do they enforce this?

  169. The other institution is notified by the one that was jilted and withdraws the acceptance. It is taken very seriously. If the level of financial aid will be make or break, the student cannot apply ED the final financial aid decisions or fancy merit scholarships are awarded in the spring.

  170. @Finn: That is exactly what she is thinking. Meanwhile, I am happy because it gives her good options if she elects against med school.

  171. The other institution is notified by the one that was jilted and withdraws the acceptance. It is taken very seriously. If the level of financial aid will be make or break, the student cannot apply ED the final financial aid decisions or fancy merit scholarships are awarded in the spring.

    How do they know where else you applied?

  172. “How do they know where else you applied?”

    I’ve heard that many schools require the student, parents, and the HS college counselor to sign an agreement. One possible source of this is the HS college counselor.

  173. CoC, I tried to post a response to Austin’s question about EA/ED, but it seems to have gotten stuck somewhere.

    Perhaps I’ll try repost it in pieces. It was a bit long.

  174. One advantage of EA/ED applications, beyond what Fred mentioned, is that an acceptance can greatly reduce the number of applications submitted, which not only saves the kid time and stress, but also saves the parents money in app fees. DS getting an early acceptance probably means he goes from as many as 12 to 14 apps down to about 7 or 8, and three of them are there mainly because they gave him waivers on the app fees.

  175. DS and I discussed this early on and he decided not to apply ED anywhere because he does not have a definite top choice, and we also wanted to see what kind of aid offers he gets, so he picked, from his initial list of schools, the EA school that ticked most of his boxes.

    In hindsight, we should’ve had him also apply early to a public school like UA (RT) that offers either EA or rolling admissions and provides early notification of acceptance. On CC, a lot of parents posted about getting acceptances as early as October, which takes a lot of stress off the kids and allows them to focus more on school and to enjoy their last years in HS more.

  176. Some of the more selective private schools have Restricted Early Action (REA) or Single Choice Early Action (SCEA), different names for the same thing, in which their EA applicants are restricted to applying to only a single private school early. There are no restrictions on early applications to public schools, and you are also allowed to apply early (not necessarily EA or ED) to schools that have early deadlines to be considered for financial aid (e.g., USC, BU, both of which offer NMF aid and have a 12/1 deadline for consideration for aid).

  177. Others have mostly replied to Rhett’s suggestion about docs trained in other countries coming to the US. I just want to point out that it is possible–if they are willing to do the US training. The husband of a friend did this, coming from the UK. They lived in Detroit for several years while he did the retraining, and then he practiced in some very rural area of Tennessee while they lived in Atlanta. It was a very long commute for him, but he worked something like 24 hr ER shifts. They have since moved to Qatar. No idea about what retraining was required there.

    Laura, if your daughter does decide to go military and you want to keep her out of a warzone, you will have to look at what each branch of the military is doing at the time and decide strategically. My dad did part of his residency at a city general hospital, so he knew how to do a quick tracheotomy and other things that could be handy on a battlefield. This was the mid-60s, so the Vietnam war was ramping up. He knew that if he joined the Army, it was very likely that he’d be sent to war. Oddly enough, the Army (I think) was doing all the flying and bomb-dropping, while the Air Force was not. He joined the AF and had two good years in the Great North Woods. He got out just before they stopped all discharges. But I’m rooting for her to be a bio engineer. If saacy swings back that direction (right now he wants to be a legislator), they could open a shop together, or at least say hi at conferences.

  178. The healthcare system in Cuba isn’t as great as it sounds. The hospitals look like the set of a horror film; plus any anesthesia, blankets, etc. you’d need would have to be paid for by the patient (who typically makes $14-60 a month).

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