See this post: http://www.janegalt.net/blog/archives/005205.html

Her academic work has the same sort of sizeable omissions that bias the results. She’s the author of the recently famous study showing that 50% of all bankruptcies were caused by medical bills. You should read the Zywicki post I linked above, but to summarise here, this “finding” was generated by attributing any bankruptcy in which the filer had more than $1,000 in out-of-pocket expenses in the last 12 months to medical bills. That’s ridiculously lax, and indeed, only 28% of the respondants attributed their trouble to medical problems. Given that medical bills are by far the most attractive reason to claim for your bankruptcy (compared to other major causes like divorce, compulsive gambling, and total financial irresponsibility), it seems unlikely that there’s a special “hidden” kind of medical bankruptcy so subtle that the people filing don’t realise that medical woes were the source of their problems. Furthermore, the study seems to have implied that medical bills were the main problem, when loss of income due to illness plays at least as great a role.

Yeah, Ennis, but not quite that last part about life expectancy in the impoverished (it’s kinda like the low life expectancy in African American males living in the ghettos of the US; impoverished people don’t eat as well, live as well (i.e.–violence), and encounter death earlier than the privileged). But you are right that impoverished communities do not have much mobility and access to medical care despite recent social movements in their favor (one being the intriguing controversy of seat reservation for Untouchables in medical college as a state effort to offset severe underrepresentation of this demographic in the medical profession–could theoretically improve the disconnect between health care and those in poverty if India was a Utopian society…:P).

Anyway, 10% in India are insured, that does not mean the other 90% are not getting medical services. The concern being addressed by the implementation of a health insurance system is in eliminating the disparate qualities of care received by those individuals capable of affording it. This still inevitably is targeting the middle and maybe (though I highly doubt it would) the working class. While one can argue that Indian society is increasingly getting gentrified, what with the new middle class, etc., most of the population is still in deep, debilitating poverty. Health insurance will only insure health to those who can afford it, and there the concern is more fundamentally in getting medical services to those who need it.

Now, there are privately owned clinics run by somewhat noble physicians who target the impoverished demographic in India. So the impoverished don’t actually need health insurance to gain treatment. And as far as (impoverished) community participation goes in these health projects, the so-called “slum dwelling” residents learn by “word of mouth” of certain clinics which accept patients with little or no money. However, when an entire demographic is marginalized from the health care system by their socioeconomic status and by racialization (i.e.–as untouchables), no health project to eliminate health inequity can maneuver around an historic exclusion (over 2.5 millenia, shout out to M. Nam’s mention of that being “0.0001% of civilized existence”) of a huge chunk of society from the health care system. The problem for the impoverished is not for them to find doctors to treat them, but in their finding doctors to treat them in time, like Camille mentions about neglect (it probably goes both ways).

From my work in a privately run clinic in Bangalore, I saw hundreds of patients walk in with terminal stomach cancer, a common disease in this community which usually goes into remission with chemotherapy and early detection, because they just didn’t feel entitled to accessing health care until, sadly, the end. This was when family members, mainly women, could not stay home, rather than trying to scrape up a few more cents “working” somewhere during the day, to care for the ill. When impoverished patients are not empowered to obtain medical services, no superficial standardized insurance plan will help them, and I agree on sowhat’s stance on it being not so great a solution.

While I’m not automatically enthusiastic about all things “micro” or “grassroots”, despite all their limitations of scope and scalability, this sounds like a welcome step indeed.

As for your point on ‘scalability,’ Ennis, what can the so-called “slum-dwellers” do to ‘jump scale’ (in Neil Smith’s words) when there is no physician (conceivably) that lives in the slums, thereby making health care spatially inaccessible to the ill, confined both by their poor health and social status in these neighborhoods? These are the ghettos of India and the ghettos of health we are talking about here. Residential segregation itself plays a huge role, along with so much more, in how not-so-easy a solution it would be to bring medical care, that too equal medical care, to the slum, rural and poor areas of India. Nice point there.

I think the microinsurance is better than nothing, but at the same time it is important to remember that so many people still go to ayurvedic/homeopathic doctors for their ailments. That type of care may be overlooked in published accounts of healthcare.

first cent goes poor sanitation and general squalor, especially tainted drinking water and prevalence of fecal matter, leading people to fall sick.

second cent goes to a fatalistic mindset and culture in which the sick are sick, by fate, or karma, or whatever; no need to find out why, what they’re sick with, whether it is contagious, whether they should be quarantined, or how to prevent a repeat of the incident. No finger-pointing, no blame-game. On the plus-side, no lawsuits, on the negative side, no correction.

yeah, that was the point of HMOs when they were first introduced, and BOY did that go over well… ;P but seriously, even if insurance companies did manage to really incentivize primary care, it still wouldn’t help those 40 million americans who don’t have health insurance and use the ER as their primary point of contact with the healthcare system. although they should still learn how to use and appreciate it, most people covered by private insurance are the ones who need the primary care the least; by and large those people are of higher income and education, whose general health is better than those w/o insurance, lack education, and are closer to (or below) the poverty line.

the contention that ANYONE is getting “something for nothing” in American-style insurance is ridiculous

American-style insurance? I’m not aware of American-style gambling or British-style cheating or Indian-style pregnancies.

Regarding something for nothing…

Person A buys insurance @5K/Yr(rest provided by employer). After ten years, she loses her job and hence, her insurance. During the course of those 10 years, she’s spent a total of about 5K on well visits, pap-smears, fevers etc etc. Person B, meanwhile buys insurance at year two of A at the same cost, and goes skiing, breaks his back, and needs acute care support @30K/yr for five years.

I’d like you to do some math to see who pays more into the system, who takes more out, and who is subsidizing whom. This is a very simple case. Sowhat made a very good point when he/she said that insurance companies have to hide costs of insurance in order to stay in business. That’s how the scam works.

.The insurance companies are a way for people to pool resources so that they can afford an essential service that is fundamentally unaffordable at the individual level.

Then the focus should be on addressing why those services are unaffordable. Tort lawyers? Restricted admissions by AMA? Excessive paperwork? Lack of transperancy?

Some people will draw more from that pool than others.

So you agree – somebody gets something for nothing (or more for little).

The fact that insurers profit is not necessarily wrong either Of course not. Nobody’s forcing you to insure yourself.

>>(as long as those profits aren’t exorbitant >

What exactly is exhorbitant? How/Who would determine this?

ALL major illnesses in the West are much more complicated than a single, expensive event. heart attack or initial chemotherapy to send cancer into remission, is horrendously expensive on its own.US system is the focus on acute care

Have you ever considered that those people who need expensive care but cannot afford it should, you know, die? For the better part of civilisation, that’s how it’s been. Somewhere in the last few decades arose this notion that every life is equally precious, even though some others have to contribute (unwillingly) to save them. This notion is against nature and will die out in the recent future. Empathy is reserved for people whom you know and love – not for strangers whose face you don’t even see.

agree that a universal, single-payer safety net would be great. And it would be a hell of a lot cheaper. And I really want one in the US

Sorry – I don’t want one. Universal health care works well in Germany, even better in Canada, better than that in Singapore and even better in Macau. Did you get the drift? Probably not. As countries get smaller and smaller, universal healthcare keeps getting better, because the overheads keep getting lower and transparency keeps increasing. For a country as big as the US, it will be crippling. For India, it will be a death sentence.

Camille:

Most of the distortion in health costs and the U.S. system being wasteful/screwed up is because of the regulatory problems and mini-monopolies that insurance companies create..medical billing, I agree – the system is notoriously complicated and redundant and overall ridiculous.

Any system where someone gets more for less (better expression than something for nothing) will have to create large enough smoke-screens to confuse those participants who get less for more.

drrty_punjabi asked me if I have health insurance. Why would I refuse something that the employer provides? Moreover…

Which of you belong to a gang? Probably none. But should you ever go to prison, you have to join a gang to survive. That’s because the system is rigged against the loners – however physically fit they are.

I never had insurance in India. Most of my relatives/friends still don’t. They all “pay as they go”. But when I came to the US, I realised that not having insurance was not an option. Even simple procedures were financially crippling – primarily because insurance companies have rigged the system (along with hospitals etc) so that you cannot do without them. So I joined the State Farm gang.

But this post is not about the US. This post was to emphasise that the insurance system is inherently flawed, and it’s a good thing India has not caught on to it. For the sake of India’s poor, it’s best to stay away from this method of healthcare.

M. Nam

But shafting primary care doesn’t HAVE to be a function of insurance. One would think that a truly savvy insurance company would actually incentivize it (keeps cost down over the long run).

And what’s wrong with that? Also, with respect to acute care, I feel like Medicare is a whole other beast of “what not to do” in health care policy.

I don’t think there is anything wrong at all with the h/ins system being a subsidy for the sick, in fact i’m all for it… i was just trying to make the point that health insurance isn’t just about pooling resources and hedging against risk.

That said, how do you figure that a single payer system would reduce those problems? (I’m just curious and have been out of the country for a while, so I’m interested to hear what kind of health care conversations are still bubbling)

I want to make sure to be clear here — a single payer system is NOT the answer to ALL of the US’ problems. however in terms of the efficiency losses from administrative overhead, it could go a long way. what i don’t understand is why municipal/public provision of other public goods (such as water, electricity) is taken as a given, but health care is not? it makes just as much sense to have a “choice” of 15 sewer systems as it does to have a “choice” of 15 healthcare payers. Some nerds up in cambridge published a study recently comparing Administrative costs in the US to (everyone’s favorite comparative whipping boy) Canada, and health admin costs in the US are about 3x as high ($1,000 per capita vs. $300). When 30% of total spending goes to administrative overhead, a 2/3 reduction in costs would have a large overall impact. [see Woolhandler S, Campbell T, Himmelstein D, “Costs of Health Care Administration in the United States and Canada,” N Engl J Med 2003;349:768-75).

Politcally, the single payer system in the US is a dead idea, but that doesn’t mean other countries can’t learn from our mistakes and choose not to go there (and that i can’t still keep hoping and wishing).

btw, i’d be interested to hear what you think is so terrible about Medicare?

Neal:

By the time you’re racking up those big end-of-life costs, and doctors are performing “heroic measures” to keep you alive, you’re not really calling the shots anymore. America has a bigger focus on acute care than other countries, but that’s a function of our medical culture than any sort of patient-choice issue.

I disagree. While the focus on acute care is a function of our medical culture, that stems from patient choice. Alot of that culture arose because insurance was there to shelter patients from the true cost of their healthcare consumption, so patients learned to demand more and more acute care. I spent the last 2 years doing research on case management interventions of chronically ill Medicare beneficiaries. This is the population that are among the biggest ‘consumers’ of heatlhcare in the US. Case management is relatively cheap, and everyone knows how to keep a diabetic or someone with CHF or COPD out of the hospital. For $100/mo, you can provide intensive case management and primary care that keeps chronic diseases in check. However, most of the programs failed because patient attitudes were focused on acute care — instead of following a $100 protocol, patients repeatedly ended up in the hospital, with an average cost of more than $5,000/mo. We’re not talking about heroic measures when someone is on their deathbed (although i do think people should go to hospice and prepare for transition rather than throwing the ICD-9 book at patients), we’re talking about near-end of life measures where patients are hospitalized up to 10 times a year. For most of these patients, they do have the power to stay relatively healthy, control their symptoms, and stay out of the hospital. unfortuantely, most of them have been systemically trained for 65+ years to rely on acute care rather than primary.

you make a very good point that perhaps India shouldn’t be thinking of the Western hospital/doctor health paradigm. i couldn’t agree more. The US focused on acute care, resulting in a patented lack of focus on primary care. so when it really counts, patients just don’t understand how beneficial primary care can be. i blame the evil insurance companies for this.

By estimating the middle class to comprise about 23% of India’s total population, (~250,000,000 people) and only 70 million of those are insured, that’s not even one third. Furthermore, (by the same prior article in FA,) if “1 percent of the country’s poor have crossed the poverty line every year” yet

About one-fourth of hospitalized Indians fall below the poverty line as a direct result of their hospital expenses

then we really aren’t making any progress whatsoever in terms of solving this enormous problem. This sucks.

I don’t see for-profit insurance as a necessarily bad thing

The problem arises when you open the door to privatization before establishing some sort of system that can encapsulate those that can’t afford this type of privileged care. As India has done.

not all universal coverage schemes involve free coverage — many of them rely on subsidized coverage with co-pays, etc.

i.e. Canada, which will cover almost the entire cost of the physician and hospital visit, however only offers to subsidize drug coverage and dentistry. However, as Camille so delightfully pointed out:

the system is notoriously complicated and redundant and overall ridiculous

Having now enjoyed the perks/pitfalls of both systems I can speak for both in that neither effectively addresses the health care concerns for those in low income brackets. At this point I’m not sure which would provide a better option for India, because of its interesting dichotomy in terms of a large poverty base (heck, even the middle class) that the government cannot afford to provide health insurance for. Perhaps we can look to a mixture of both private/public sometime in the future, as some of you have suggested (like in Europe.)

I still believe micro insurance is a step in the right direction.

I would say it’s both a subsidy for the sick and resource pooling measure. Every person on this planet is going to get sick at some point.

I’m also a little confused by your point about acute care. By the time you’re racking up those big end-of-life costs, and doctors are performing “heroic measures” to keep you alive, you’re not really calling the shots anymore. America has a bigger focus on acute care than other countries, but that’s a function of our medical culture than any sort of patient-choice issue.