Even With the ACA, the U.S. Healthcare System Is Still F-cking Stupid

So, at the new job, I’ve been suffering through all of the orientation stuff, and what I’ve noticed, regarding healthcare, is that the ACA (Obamacare) notwithstanding, I’m still facing the same idiocy I did seven years ago when I switched jobs. At the new job, I can choose among 23 different healthcare plans.

Yes, twenty-three. Sure, they can be grouped into some broad classes: catastrophic insurance only, fee-for-service/PPO (high-end), and HMO-like plans. But within each of these categories, some of the plans have to be worse than others. Worse, since I can’t determine ahead of time what my medical needs will be (hopefully, minimal), I have no idea which plans’ specialists are the ones I might need. It sort of defeats the concept of pooled insurance.

I watched a room full of smart people, many with advanced degrees, get frustrated as we all realized we would waste a lot of time trying to pick the ‘best’ plan–with no idea if or how we’ll succeed or fail.

This is something I discussed seven years ago and it’s still a problem:

….a point that needs to be raised, even if it is obvious:

There is a difference between health insurance and healthcare.

Granted, even Yogi Berra probably wouldn’t have said something this obvious. What led me to blunder into the obvious was having to decide which health insurance plan to choose at my new job. I had a total of seven different health insurance plans to choose from, three of which were HMOs. The HMOs were the most interesting: the most expensive was $173/month (for an individual), and the least was $118/month. As far as I could tell based on the benefits package, the $118/month was the ‘you are legally required in Massachusetts to have health insurance, but if anything happens other than an annual checkup, you’re hosed’ plan. But I could be wrong: maybe someone paying $173 per month is just wasting his or her money. Or maybe we’re both screwed if something bad happens.

The problem is that I have no way to evaluate how good any of these plan are at keeping me healthy, which is what I care about–hence, the above distinction between health insurance and healthcare.

This isn’t ‘choice’, but an overwhelming amount of information that will result in some (or many) people getting screwed. Hard to believe that’s efficient.

We could have done much better.

Added: After writing this post, I stumbled across this by Dr. Michael Gorback (boldface mine):

The point of this exercise is not that there were cheaper drugs available that had the same pharmacologic action (a topic for another day) but that my insurer could change the rules without my knowledge or approval.

As it turns out, when you purchase a health insurance policy, you only think you know what you’re buying. You know parameters such as the deductible, coinsurance, premium, maximum out of pocket, and so on. You know whether or not you have maternity coverage, psychiatry coverage, a lifetime cap – and all sorts of nonspecific things.

But the devil doesn’t lurk in nonspecific things, does he? Your policy documents don’t specifically say that certain drugs aren’t covered, or that you might have to try one or more other drugs before they will cover it, or they might refuse to cover it because your condition is not listed as an FDA-approved use for the drug.

One of my colleagues relates an amusing story about this hypocritical farce. He prescribed pregabalin for a patient. The insurer denied it. He spoke with a doctor at the insurance company, who said they wouldn’t cover pregabalin because it wasn’t FDA-approved for that condition. He said they would cover a very similar drug called gabapentin. Gabapentin is cheaper than pregabalin. My colleague then observed that gabapentin wasn’t FDA-approved for that condition either. Upon which the insurance company authorized pregabalin. Or was it pre-authorized?

When it comes to hospital services you might know that they will pay for 60% of charges after the deductible is met, but what you don’t know is what rates they have contracted with providers of healthcare services. Suppose your insurer has negotiated a price of $1,000 for your surgery with the XYZ hospital chain. Another company might have negotiated $800….

There is no way you can know any of this when you sign your contract. Even if you could, they can change it whenever they feel like it, just like they did to me. One year they might pay for a certain treatment, the next year they might decide there’s not enough evidence and your coverage is gone.

You have to use your policy if you want to find out what’s in it.


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13 Responses to Even With the ACA, the U.S. Healthcare System Is Still F-cking Stupid

  1. RJ says:

    As a temporary measure, Americans need to form non-profit associations devoted to helping people choose a good plan, cutting the crap. As you note, it is almost impossible for an individual to do this work effectively.

    Of course, those people most likely to do this are Democrats, and forming these associations would be a not-very-implicit admission that the ACA is half-assed. Such is life, I guess. Maybe it would put on pressure to improve the plan.

    Lucky I’m Canadian. I just show up at the doctor’s office.

  2. anthrosciguy says:

    My girlfriend is Canadian. She applies for medical coverage by filling out the form and showing ID and … that’s it. If her granddaughter, who has dual US and Canadian citizenship, decides to live in Canada as she says she’d like to, same process. Co-pay? no. deductible? no. No figuring out how much you need to pay to get the level of service you need. Just fill out the form, show your ID, and after that you just wave your card at the doctor or hospital and get your treatment and go home.

    I’ve got insurance through a pension plan in the US. $3,000 deductible. It was cheaper for me to go to Thailand and have my hernia operation than to do it in the US. (And much much faster.)

  3. NewEnglandBob says:

    The way I see it, health insurance is health care prevention. The companies go all out trying to prevent us from proper medication and proper treatments.

  4. Janice in Toronto says:

    Jebus. What is wrong with you people? Is it not plain as day that Canada and many other countries’ socialized health care is light years better? Everyone gets care. No one is left out. The American system is just cruel.

  5. paintedjaguar says:

    Not “stupid”. Insane. And insanely cruel. But very good at putting cash into the right people’s pockets.

    “Even With the ACA”? Oh, please. The ACA was designed from the ground up to keep U.S. heathcare locked into the same insanity. It was never intended to make things better for most of us. I suppose people might finally catch on after it’s so firmly embedded that there’s no chance to get rid of it.

  6. RJ says:

    I keep hearing that ACA might function politically as a stepping-stone to a better system. Obama was forced to come out in favour of gay marriage by political pressure. Perhaps a future nominally liberal prez could be pushed in the same way, for a half-civilized heath insurance system.

    Hope so. It hurts me to see people living in the richest country in the world with such shitty heath care.

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  8. Horace Boothroyd III says:

    America’s health care system is indeed fucking stupid, but it is significantly less fucking stupid than it would be if we had allowed you ineffectual pseudoradical jerkoffs to make common cause with the teahadis and torpedo reform for yet another generation. While my heart bleeds for your mental inability to deal with a platter of 23 insurance options, the millions of working poor who will not suffer needless pain and death fill my heart with a vastly greater happiness – as is the case for every decent person who is not a stone cold psychopath.

  9. anthrosciguy says:

    Horace, noting that the system we set up is nowhere near as good as a system we could have set up is not the same as the strawman you’re knocking down. But you were indeed very brave to attack that strawman — it was a fierce looking construction — and you kicked and kicked it most thoroughly. I hope you videoed it and will have it on YouTube soon; may you get many hits.

  10. jemand says:

    I know one thing about my insurance: my union has negotiated this contract with my employer and the company. I know a lot of people spent a lot of time on my behalf to work this out.

    It’s great.

  11. “I know a lot of people spent a lot of time on my behalf to work this out.”

    But then the ACA isn’t for you. It’s for people like me: I’m a freelance translator and don’t have someone to work this out for me. Well, actually, I live in Japan, where there’s always been government-run affordable health care for everyone, include we who don’t work for a big company/organization. Which is to say, that moving back to the US would have been completely unthinkable for me any time in the 25 years I’ve been a freelancer.

    For all the grumping about the ACA, it’s worlds better than the situation before, where everyone working freelance, part time, or trying to start a small business was at the mercy of the insurance companies, who would only sell you insurance if you could prove that you’d never been sick, would look for the slightest excuse to refuse to pay claims, and would pocket the difference. Not having your medical history as a condition of purchasing health insurance is enormous. Having subsidies if you can’t really afford full price is enormous. Forcing insurance companies to return excess profits to policy purchasers is enormous, since now, within certain limits at least, there’s no point in refusing claims: the money would just have to be refunded.

    Sure, there’s still a long way to go to being anywhere near as good as Japan, but at least the US is now in the same ballpark.

    • jemand says:

      Trust me, I know– I grew up without any insurance before I got this job. Occasionally went without some care, watched my parents go without a lot more often. Just because I have a union now doesn’t mean I always will… (in fact, I *have* to leave here within a couple years from now, the job is not a permanent one for anyone.) But I take every chance I can to point out the benefits to me from being in a union, especially since a lot of people seem to think unions *only* work for a permanent kind of workforce. I wish we could move more towards a unionized workforce here, even for people moving in and out of different jobs.

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