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How medical insurance works
(lemmy.world)
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this post was submitted on 07 Oct 2024
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Can someone explain how universal healthcare would solve this issue? It seems like an additional problem beyond the fact that prices are gouged based on insurance that not everyone has. On top of that bullshit, insurance does this stuff. What about universal health care, if implemented tomorrow in the US, would make it different?
(Side note: I love how I get all these downvotes for trying to learn more! What a fucking asshole, right? Yall are too used to trolls, grow up and humble yourselves. Learn to distinguish asking about how barriers work from advocating for those barriers to stay. Jesus fucking christ some of you are so much dumber than you realize you are.)
There wouldn't be an insurance company to tell you no in a single payer system
Damn. That's gonna be really hard to get to in the US. Several steps at least. I'm guessing the next step that we can work for is just guaranteeing universal coverage. But there's gonna be bloody battles over just removing an entire industry from the US market in our lifetime. So I guess this problem is here to stay, even if we're lucky enough to get guaranteed coverage regardless of employment.
Yeah that's what the ACA was supposed to do. Until it got neutered and eventually destroyed.
The whole premise was based on the three-legged stool:
Problem is, a stool with three legs is pretty stable, until you shorten or remove one or more, like the individual mandate or the tax subsidies, the whole thing topples over.
One problem was the carrier responsibility leg was too short. Should have been more aggressive in making sure that premiums could not out-pace inflation or otherwise rise over a certain threshold year-over-year.
The other problem is the welfare gap that gets created when you have the individual mandate and not enough funding for Medicare/Medicaid subsidies. You end up with a big chunk of otherwise healthy people who now are forced to either buy (very expensive and not employer sponsored) health insurance, or face a significant tax penalty. The people who got stuck in the middle were rightfully pissed off.
(And surprise surprise, the ones that got stuck in the middle were largely in red states, because they wanted to starve the medicaid beast).
But of course, instead of fixing it by upping the subsidies, we fixed it by removing the individual mandate. In other words, instead of putting a matchbook under the short leg, we completely removed the squeaky one. Now the whole damn stool is falling over and nobody wants to catch it.
It's actually very easy. Force all insurance companies to segregate their health insurance. Nationalise all health insurance.
That's what I'm saying is going to be the hard part. Force the industry to gut themselves. Aren't they the ones paying for our politicians careers? If it were that simple, why hasn't it been done already?
Yup. Which politicians are going to vote to make lobbying illegal?
There wouldn't be a for-profit middleman taking billions out of the system for themselves yearly.
Critics point out that government-run healthcare would be less efficient and would also have to draw the line in approving/denying care somewhere too, but I can only imagine that it would pale in comparison to the insurance companies who have a profit-motive to screw you over.
Supporting this assumption is the fact that Americans already spend way more on healthcare than other countries, even those that already have universal:
So, basically we're all overspending solely to make insurance companies rich.
Hey but we're 60th in life expectancy in the world! So... wait.
How things work in BC:
When a practitioner changes for a service, they can't bill any more than what the Payment Schedule says that procedure costs. So if the Medical Services Plan isn't being billed (eg the doctor or patient opted out of MSP, the patient is a non-resident, the service is in the Payment Schedule but the Payment Schedule requirements consider it unnecessary) or MSP isn't covering the full cost (some stuff like a second or third biopsy will only be covered 50 %), then the doctor can't bill the patient any more than they would've billed MSP. This means practitioners have no incentive to not bill MSP.
The Payment Schedule (and thus allocation of the MSP budget) is set out by the Medical Services Commission which is composed of three representatives from the government, three from the Doctors of BC (the professional association which promotes the interests of member doctors) and three members of the public. So even if the government pushes for more stringent coverage requirements and budget surplus, the doctors are there to push for higher fees and less billing paperwork (besides exceptional circumstances like out-of-country care, patients can't submit claims directly; everything is on the practitioner's end), and the public is there to push for more coverage.
In practice this means that for the vast vast majority of services, the only justification that the practitioner needs to give MSP for coverage is the International Classification of Diseases diagnostic code for the condition being treated.
Brit here. Not saying the NHS has no problems, long waiting lists being the most obvious, and on a practical/personal note shared wards, but at least in principle if the doc says you need X then you get X. There's no beancounter to persuade that you really need this thing who then says no anyway. There might be another step: GP -> specialist -> diagnosis -> solution but in principle it's pretty straightforward. It's funded by a 9% tax so you pay according to your ability, and it's free at the point of delivery to all British citizens.
If the solution is a pill or potion from the chemist then you get it free if you're on a low income, but at a capped price on prescription.
Because it's free to use, you (can) go to the doc as soon as you have a problem, unlike in the USA where you dread massive bills so you hope it goes away on its own, meanwhile it gets worse so you go when you have to and when the bills are at their highest. And because the NHS is tied into the government who regulate the pharmaceutical industry they (should but don't always) get best prices on everything, along with bulk discounts because it's just one buyer for the whole country.
I'm probably oversimplifying a lot here; I don't work in the NHS so this is just my view as an outsider. I think there are some regional variations; every so often "NHS postcode lottery" comes up in the news, but I don't know how they work.