Strangely, a study on whether providing expanded medicaid* would reduce emergency room visits seemed to suggest that it did not:
> It was widely believed that having insurance would encourage people to get routine medical care in doctors' offices or clinics, instead of waiting until they have more serious symptoms and have to head to the ER, where care is most expensive.
> The study's first findings, published a few years ago, showed that Medicaid was beneficial in many ways. It improved people's financial security. They went to the doctor when they were sick. And having the insurance correlated with a drop in rates of depression.
> But the study also found Medicaid enrollees increased their emergency room visits by 40 percent over the first 15 months.
It's odd that the rates of going to the ER are discussed, but not the content or cost of the care during the visits... particularly when the article discusses the speculation that the increased visits might be doctors referring patients to the ER to take care of some specific condition... and you would think that would be lower cost than catastrophic care later.
> and you would think that would be lower cost than catastrophic care later.
That's the whole question.
It's possible that people without insurance would have just never gone to the doctor and then died without ever being treated by anyone. Dying of some preventable condition is obviously worse for them, but it doesn't inherently result in more money being spent on healthcare.
And if you look at rates of visits, while ignoring cost/content of the visits it seems like you're missing a big part of the analysis.
Sure, letting people suffer and die is cheaper on the medical systems books - but people dying earlier than they need to is a negative cost on our society and larger economys side ... let alone the ethical questions there.
> And if you look at rates of visits, while ignoring cost/content of the visits it seems like you're missing a big part of the analysis.
Not so much, because of the way emergency rooms work. What costs is the capacity, not what you use it for. You have to pay the going rate for a surgeon who can do open heart surgery, even if that doctor is only administering aspirin for a headache.
That's why a $.25 band-aid costs $100 at an ER.
> Sure, letting people suffer and die is cheaper on the medical systems books - but people dying earlier than they need to is a negative cost on our society and larger economys side ... let alone the ethical questions there.
But the original problem was that people can't afford healthcare, either individually out of pocket or collectively as insurance premiums or taxes. If covering more people under government insurance doesn't reduce costs then it doesn't solve the problem -- people still won't be able to afford healthcare.
It doesn't help anything to make it mandatory as taxes so that they end up not being able to afford rent or food instead of health insurance. We need to figure out how to actually reduce costs so that the amount of healthcare people need costs less than the amount of money they have, so that it's possible for people to get healthcare without going bankrupt.
That probably means people paying for more things out of pocket, because out of pocket payments shouldn't have triple the expense due to insurance paperwork, and people only compare prices when it's their own money.
> But the original problem was that people can't afford healthcare, either individually out of pocket or collectively as insurance premiums or taxes. If covering more people under government insurance doesn't reduce costs then it doesn't solve the problem -- people still won't be able to afford healthcare.
There is a wealth of data that shows that the problem with health costs is in fact solved by strong government involvement in health care in systems where people don't pay out of pocket at all ... ignoring that data is willful ignorance.
Proposing alternatives government involvement are interesting, but not very constructive if we can't even get to the point of agreement of how well real world health systems perform in other nations vs the US.
> There is a wealth of data that shows that the problem with health costs is in fact solved by strong government involvement in health care in systems where people don't pay out of pocket at all
Just comparing costs doesn't work when there are so many asymmetries.
The US has far lower density than those countries, which increases costs because it makes it necessary to have a lot more idle capacity in order to maintain a reasonable emergency response time.
And a big part of the cost that the US system pays and nationalized systems don't is actually legitimate -- it pays for medical R&D. If we just regulated prices like other countries then that money disappears -- which is fairer, but that doesn't mean it wouldn't cost lives. Other countries have lower costs because they're ripping us off by not paying an equal share. Unless you can convince them to pay more, we can't eliminate that cost without eliminating the research it pays for.
Moreover, there is no question that parts of the US system are terrible -- especially the insurance companies and the amount of overhead and inefficiency that comes from using "insurance" to pay for non-catastrophic care. But it should be possible (politics and corruption notwithstanding) to change that part of the system without nationalizing the whole thing.
Because national healthcare has its own problems. From your link:
> In Japan, if spending in a specific area seems to be growing faster than projected, they lower fees for that area.
That's the bureaucratic solution. It absolutely works to keep prices down. As long as you don't mind that it implies responding to demand by spreading the existing resources thinner without regard to how that affects outcomes.
There is a reason the US has a worse average but a better median. There have to be ways to reduce costs and help the bottom 20% without hurting the middle -- and that's the only thing that will pass anyway, because you can't get 50% of the votes with something that will reduce the quality of care for the other 80% of people.
> The US has far lower density than those countries, which increases costs because it makes it necessary to have a lot more idle capacity in order to maintain a reasonable emergency response time.
The density argument doesn't make sense. If that were true, New Jersey would have cheap healthcare on par with "those countries" that have similar population densities. New Jersey would also have cheap, super-fast broadband and a robust statewide public transportation system, other things that people claim the U.S. simply can't do because population density.
Healthcare costs do very significantly from state to state. But density isn't the only factor.
For example, one of the strongest indicators of high healthcare costs is having a Democratic majority in the local legislature, which tends to correlate with density and cancel out the benefit. If you look at the red states you can clearly see the effect of density -- the higher density southern red states (Texas/Georgia/Virginia/Carolinas) have lower healthcare costs than the lower density northern red states (Alaska/Wyoming/Nebraska/Dakotas).
From another article on the same study (albeit earlier):
> "Medicaid coverage increases emergency department use, both overall and for a broad range of types of visits, conditions, and subpopulations," says Amy Finkelstein, an economics professor at MIT and one of the authors of the study.
> "Including visits for conditions that may be most readily treatable in primary care settings."
"Including visits for conditions that may be most readily treatable in primary care settings."
That's just engrained practice. People used to go to the ER instead of a regular physician, now they continue what they always did. You ask yourself why the hospital doesn't set up a regular practice on the premises and has triage send patients there.
> You ask yourself why the hospital doesn't set up a regular practice on the premises and has triage send patients there.
In Texas, they are legally prohibited from doing so. They would have to send you to a physically-separate location, even if said location was still in the hospital's parent network.
Well, what does one expect when the answer given by many when the topic of socialized medicine comes is "go to the emergency room, they can't turn you away for having no money"?
Especially when it covers non-citizens and people who are illegally in the country.
We could at least have a little compromise by making health care more tiered so that citizens, payers and people with insurance receive better health care than others. Make a list of services that will only be provided to payers and automatically push non-payers to the back of the queue.
I'm amazed sometimes the things people say here. The idea of withholding medical care based on citizenship comes very close the criteria for evil, with the drawback that it's largely incorrect, too (non-citizen residents, legal and illegal pay taxes at many levels of government for far less in return comparably than citizens).
What is the maximum amount we should spend to save a human? A million? A billion?
Should society absorb any cost to save a human even if it gets exponentially more expensive with each subsequent procedure? Or should there be a cutoff where you are basically told "Sorry, you've exceeded the threshold and have to either pay for it yourself or die"
It would seem that the cost of being stingy here is that the medical care system is more expensive for less performance in the US. Cut off your nose to spite your face exemplified.
This is a non-sequitur, and not related to the original topic which was: Should non-citizens be disallowed from receiving ER care without paying for it themselves?
Additionally, we already had that system in place, it was called "lifetime limits" and it was typically $1-2m on the best healthcare plans.
It's not withholding health care. It's withholding American tax money from being used for people who are not Americans. They're free to pay for health care for themselves.
I'm not a citizen. I come here legally. I pay my taxes. I pay for my insurance. This is not the minority case by the way, all your H1b colleagues as well as F1/J1 students are like this. Should we still die because we're not American citizens?
I think the idea being that generally, two people going to the same ER one being broke and the other being loaded are going to get a similar level of emergency care. Long term maybe not but you aren't going to get the bronze plan of gunshot care while the guy next to you is enjoying platinum.
I think most people believe its morally repugnant that your value as a human being is related to how much money you have. Because choosing to serve one person over another based on money rather than their medical need is exactly that.
Ie: I broke my toe and I have insurance, so I get ER treatment, but that guy who has no insurance and is internally bleeding to death from a street stabbing (and is hispanic, doesn't have insurance and maybe isn't american?) is pushed behind me in line. That is the real life scenario that at least one person is advocating here.
I agree, I think that ER's work more or less like that now (not necessarily the rest of the hospital), I'm concerned for the future this not always being the case.
I think as the governments become more starved (not made more efficient by reducing costs, starved by simply cutting funding without optimizing it logically) that important government services will have to replaced with tiered private companies. As regulations are removed, the same thing occurs.
What if a speed of ambulance was built into your insurance? How do you know what response time is right for you and your family (as it will be framed)?
> I would view that as a horrible compromise, because it would result in poor people receiving worse health care than wealthy people.
It's impossible for that not to be the case. It's even the case in countries with single payer, because rich people who live there and don't want to wait for an appointment or want something that isn't covered will just go to a country that can give them what they want and open their wallet. Even without leaving the country, they can hire private nurses and so on when they aren't covered by the national health system.
Moreover, why is this supposed to be a problem? "Money buys things" is the purpose of money.
There are things a rational national health system wouldn't pay for because they aren't economical, but a rich person would buy for themselves for much the same reasons they buy a Tesla instead of a Dodge. Which means they have a safer car because they have more money. Should we prohibit expensive safer cars because poor people can't afford them?
Wealthy people can already buy their way to better private health care. These changes would regulate the difference between health care for the middle/upper middle class and the poor.
Although I would prefer to concentrate on the 10s of millions of non-citizens and illegal aliens who receive tax payer funded health care.
>Although I would prefer to concentrate on the 10s of millions of non-citizens and illegal aliens who receive tax payer funded health care.
I feel like I should remind you here that many non-citizens are actually tax-payers. Taxes are paid in many different ways, but let's forget about that here for a second and realize that many non-citizens actually come here legally to work.
A blanket statement like that really doesn't mean anything. Same arguments were given about dreamers using tax-payer money, without realizing many of them actually are tax-payers as well.
Not sure what citizenship has to do with this. As an American traveling in Europe, I received emergency room care. They may have glanced at my passport, but certainly did not ask for any other documents. Nor did they ask for payment.
I dont know your experience as an American, but as an Argentinian I am not allowed to enter Europe without health insurance. They dont let you on the plane without it.
Is it really fair to let poor people have health services that they didn't pay for? Is keeping poor people healthy/alive really the best allocation of resources?
Shouldn't triage take into account who is the most profitable so wealthy people can go to the front of the line where they deserve to be?
I mean really, why should my undocumented nanny, house keeper and gardeners be entitled to the same health care that I am?
[Of course, I don't pay them enough to buy health insurance but that's their problem.]
As @gselevator tweeted "I never give money to homeless people. I can't reward failure in good conscience."
How do they know I'm a citizen? Do they deny care to the unresponsive person in pajammas because they can't be sure if the person isn't a foreigner bilking the US health system?
The reason you have to wait 6 weeks is that the doctor's office does not have infinite capacity, and increasing that capacity would require adding nurses, doctors, and rooms.
Instead, the 6 weeks is a result of 1) the number of people who wish to get appointments, 2) the time that each person spends, and 3) the number of people who can be treated at a time:
That doesn't really work for medical offices. A better solution is to reserve more schedule slots each day for patients who call or just show up that day. That makes the overall system more efficient since patients with urgent symptoms don't have to go to urgent care or ER.
Urgent care is still more expensive than visiting your regular doctor. And it's less effective because the urgent care doctors are less familiar with you as a patient, so it takes longer to get up to speed on current symptoms and the risk of error is higher.
Since this is a social problem, you can add a complication that the response time has an impact on the throughput.
If people call for an appointment, and find they have openings this afternoon and tomorrow morning, they'll be more likely to go to the doctor. If they find that the earliest appointments are 12 weeks out (as I did when trying to schedule a physical before a recent trip to Asia - ended up skipping the appointment), they're going to go elsewhere.
If you're viewing the queue as a sort of plumbing system, this can be approximated as backpressure.
For the same values of 1), 2) and 3) the waiting time could be 6 weeks, 6 days or 6 months. At least I understand 1) to be the inflow (people/time) and the inverse of 2) times 3) to be the outflow, and in equilibrium both willbe equal to the throughput.
Just another report highlighting the need for change to our current healthcare system.
Although anecdotal, multiple family members who are health care providers in the ER (Nurse, PA, Doctor) it's more often than not far from an emergency ailment. This creates a scary supply and demand scenario.
I think one benefit of the emergency room is that you know it'll be open. Doctor offices follow normal working hours. Every time I've ended up in an emergency room its for something that happened in abnormal hours.
The usual solution is urgent care clinics with extended hours, although in some areas they aren't open 24 hours. Symptoms always seem to get worse at 3 AM.
Some? I'd guess that in most areas, they aren't open 24 hours. As far as I know, SF (for example) doesn't have any urgent care centers that are open overnight.
Same here. Our local urgent care places aren't open very late, so every time we've gone to the emergency room is because it's the only medical establishment open.
Yup. The system is pretty messed-up and from my view (as a user), it drives people towards ERs as there are few other options. Some examples:
1 - Any time a condition/illness causes bad nausea/vomiting, the urgent care will send you to an ER to get IV meds and fluids, which they can't do. You probably don't need a full ER, but that's the only place to go. This must be fairly common during flu season, and a huge waste of resources.
A startup idea could be an Uber for off-hour home visits. If all you need is IV fluids, check some vitals, keep you comfortable to ride-out a nasty virus, surely it's in everyone's interest to have a quick visit by a nurse/PA, possibly MD.
2 - Pain management. If you have a relatively new illness or injury that requires stronger medications to manage the pain, you have no choice but to go to an ER, or perhaps be admitted to a hospital (which is even more expensive). I can't say if over a longer period of time, for a chronic case, there are better options that eventually get worked out. But 2 months into such an issue with a family member, and going to the ER was frustratingly the only option.
3 - Chest pain. Yes, it could be a heart attack, so maybe an ER is the best place to go. You will get triage pretty quickly with an EKG, and some basic vitals, but you're still stuck there for hours if it's a false alarm (I'm guessing quite often). There's got to be a better way.
3 has been an issue for me recently. I was referred to ER for some chest discomfort, which, unfortunately, the school clinic I was studying at cannot do the blood tests to see if it's a blood clot. I was given scary words like "you could die from this if untreated".
For that reason, I visited ER twice that week, and was diagnosed with some mild stomach issue and stress. Every single test they ran gave negative result. It's a huge waste of time for me, and I feel very guilty for wasting ER resources (especially as an immigrant). There has got to be a better way.
Edit: I was very lucky to be covered under school-mandated health insurance, and I don't think you could live comfortably in the U.S. without having one.
For #3 they treat even the remote possibility of heart trouble very seriously. I went into the ER with a broken wrist and they hooked me up to an EKG first, before even examining the wrist. Later they told me it was because of my elevated heart rate and blood pressure, and because I was sweating profusely. At that point I had already told them I got the injury playing soccer, it was summer and hot outside.
Urgent Care facilities and walk-in clinics can fill the need for immediate, after-hours care at a far lower cost than the ER. Here's a screenshot from my health insurance provider, you can see it gives options along with a comparison of their cost: https://imgur.com/a/4Lqb7
Make sure that it really is an Urgent Care - there are starting to pop-up businesses which are (or at least promote themselves as) Emergency Room alternatives. They charge like an ER too, so you could end up with a large bill.
Good point, but I think that depends on whether your state allows them. I've seen standalone emergency rooms in Texas but not in Pennsylvania and New Jersey. One of my relatives in Houston is an ER doc and works at one of these standalone ER's, when I asked him why these exist (in contrast to urgent facilities) he told me it was purely because they can charge significantly higher ER rates.
Most urgent care facilities around me are only open till 8 or 9 - good enough for things that happened while you were at work but couldn't get to your GP for but the world doesn't stop after that. The few times I've been to urgent care they are so understaffed that if there are 3 people in line at 6:30 you'll be lucky to get seen by closing time.
There is a major lack of information and advertising around Urgent Care. Very very few people know Urgent care exists. And in what form does it exist. Its different across states and cities.
Comparatively, Emergency care/Ambulances are available almost everywhere through 911 AND take most of the mind space around urgent issues.
Finally, Urgent Care centers are not equipped to handle lots of things like broken bones etc. They just refer you to an emergency center instead.
I've run into this first hand. I needed an X-ray but only 1 of the 3 Urgent Care centers had the machine. I went back the next day to that UCC and the X-ray technician was out.
I know a nurse in an urgent care in Southern California. She says, never, ever, ever, go to an urgent care. Apparently her bosses (MDs and owners of the urgent care) told her to youtube how to do stitches when a patient came in that she wasn't comfortable treating on her own. Youtube. Stitches.
And Urgent Care will often just send the patient to the ER with the same company, because it makes them more money.
My girlfriend went to an Urgent Care with a stomach bug. They asked if she had any abdominal pain, and she said yes. That was a flag for them to say "We can't handle you because abdominal pain is a flag for possible appendicitus so you have to go to the Emergency Room now."
There was no way she had appendicitus. She just needed an antibiotic. But you follow the hospital's advice, and stepped into the ER and suddenly was charged $5,000 for useless tests and had to stay there for 6 hours.
just a personal anecdote (i don't think that such situation affects any significant percentage of people though) - English words "urgent" and "emergency" translates to basically the same Russian word which means "emergency". Given that "urgent care" is missing in Russian medical system (at least 20 years back it was), we, being recent arrivals and thus not very skilled in both, English language and the details of US medical system, were going to "emergency" whenever told to go to "urgent care", and we were so disappointed that regular US doctors would refuse to see us except by appointment of some weeks/month in the future when an issue would require prompt attention, and they would be sending us to "emergency" instead (as it sounded to us when in reality it was urgent care). We thought that it is such an inefficient system - either appointment in 2 months or emergency room (where we'd wait 3-4 hours - obviously our issues weren't any close to priority there, and where we obviously wouldn't get a specialist attention which would better suit the issue we came with). Sometime later (after 6 years in US :) we did accidentally learn about urgent care.
The crux is making it easier for consumers to get health care information, putting more choices in the hands of the patient, and creating a mechanism to encourage price sensitivity even if people don't pay for their care directly.
Respectfully, I feel this link is missing the broader picture - that the US has a health care system unlike any other OECD nation. Perhaps the crux is looking at models that have been successful in other countries and adapting them to the US?
America should lead the world in healthcare and many of those proposals would help us accomplish as much.
We're mired in this current system with no rationing, low accountability, and rentiers sucking cash with the Government's approval and leftist protection against any reduction to the cashflow. Look at the yelps ushered by leftists when Trump stopped giving insurers free money - many of them bemoaned the loss of corporate welfare.
The crux is making it easier for consumers to get health care information, putting more choices in the hands of the patient, and creating a mechanism to encourage price sensitivity even if people don't pay for their care directly.
I'm not seeing anything there that would help those who can't afford care. And charity is woefully inadequate, and still doesn't address needing care today.
Then you didn't read it very closely, the article devotes a decent amount of space to how to set up the system that ensures people can get care regardless of their ability to pay.
It's within the first two pages, look for the paragraph that starts with this
5. Said charges under (3) and (4) will, when submitted to Treasury
It lets people access healthcare regardless of their ability to pay for it, how is that contrary to the goal of increasing access to healthcare for the poor?
Even with insurance, they implicitly encourage people to say everything is an "emergency" because otherwise you'd have to call them to get approval. But if you say "it was an emergency" you can avoid having to jump through hoops. So you go, and it clogs the emergency room, everyone pays more.
This isn't that surprising. The cost of health care is so astronomical that many people WITH insurance refuse to go to a doctor until their condition is so bad they can't avoid it any longer, and then it's straight to the ER.
yeah having insurance, even for some of us with six figure jobs is "we give you a small tax break on the first 10,000 you spend on health care every year in exchange for paying us $300 a month!"
Here's a nice graph[0] showing the relationship between income inequality and healthcare, and a good quote:
"The high-income group, with average household income greater than $70,000, is the standard to which all others are compared... 30 percent of the population in the $30,001–$50,000 range ...have 59 percent more mortality than is true of the richest group."
The summary and headline are badly misleading. It sounds like shocking news, but what they really found is disappointing but not that surprising.
It's not half of US medical visits to any kind of medical care that are at emergency rooms. It is half of US medical visits to hospitals that are at emergency rooms.
That's a big difference. Among other things, they are not including visits to your family physician. If they included ordinary visits to your doctor outside of the hospital, then emergency rooms visits would be a much lower percentage.
It says, "Our study aimed to determine the contribution of EDs to the health care received by Americans between 1996 and 2010 and to compare it with the contribution of outpatient and inpatient services using National Ambulatory Medical Care Survey and National Hospital Discharge Survey databases."
They are comparing emergency visits to other kinds of hospital visits.
So what you're saying is, after years of providing a strong financial incentive to get all your care via emergency departments, people are surprised to what extent the population actually takes this incentive ...
Bingo, I’m so glad you clarified this. Something “didn’t smell right“ here.
Even beyond the family physician, there are many specialists that are affiliated with hospitals but see patients in their offices, outside of the hospital registration process.
In fact, those specialists often have offices in the hospital or in buildings attached to the hospital.
The disappointing part of the US medical system is it doesn’t do much for you unless you’re really seriously ill or about to die. If you’re about to die, it’s the best in the world. If you just eg have a shoulder pain or something — you will have great difficulty finding a competent doctor to deal with it. People discover this by their mid to late 30s, around the time they begin to have their first real health problems.
98 comments
[ 4.7 ms ] story [ 162 ms ] thread> It was widely believed that having insurance would encourage people to get routine medical care in doctors' offices or clinics, instead of waiting until they have more serious symptoms and have to head to the ER, where care is most expensive.
> The study's first findings, published a few years ago, showed that Medicaid was beneficial in many ways. It improved people's financial security. They went to the doctor when they were sick. And having the insurance correlated with a drop in rates of depression.
> But the study also found Medicaid enrollees increased their emergency room visits by 40 percent over the first 15 months.
[0] http://www.npr.org/sections/health-shots/2016/10/19/49852611...
edit: fixed medicare / medicaid
That's the whole question.
It's possible that people without insurance would have just never gone to the doctor and then died without ever being treated by anyone. Dying of some preventable condition is obviously worse for them, but it doesn't inherently result in more money being spent on healthcare.
Sure, letting people suffer and die is cheaper on the medical systems books - but people dying earlier than they need to is a negative cost on our society and larger economys side ... let alone the ethical questions there.
Not so much, because of the way emergency rooms work. What costs is the capacity, not what you use it for. You have to pay the going rate for a surgeon who can do open heart surgery, even if that doctor is only administering aspirin for a headache.
That's why a $.25 band-aid costs $100 at an ER.
> Sure, letting people suffer and die is cheaper on the medical systems books - but people dying earlier than they need to is a negative cost on our society and larger economys side ... let alone the ethical questions there.
But the original problem was that people can't afford healthcare, either individually out of pocket or collectively as insurance premiums or taxes. If covering more people under government insurance doesn't reduce costs then it doesn't solve the problem -- people still won't be able to afford healthcare.
It doesn't help anything to make it mandatory as taxes so that they end up not being able to afford rent or food instead of health insurance. We need to figure out how to actually reduce costs so that the amount of healthcare people need costs less than the amount of money they have, so that it's possible for people to get healthcare without going bankrupt.
That probably means people paying for more things out of pocket, because out of pocket payments shouldn't have triple the expense due to insurance paperwork, and people only compare prices when it's their own money.
There is a wealth of data that shows that the problem with health costs is in fact solved by strong government involvement in health care in systems where people don't pay out of pocket at all ... ignoring that data is willful ignorance.
http://www.pbs.org/newshour/rundown/health-costs-how-the-us-...
Proposing alternatives government involvement are interesting, but not very constructive if we can't even get to the point of agreement of how well real world health systems perform in other nations vs the US.
Just comparing costs doesn't work when there are so many asymmetries.
The US has far lower density than those countries, which increases costs because it makes it necessary to have a lot more idle capacity in order to maintain a reasonable emergency response time.
And a big part of the cost that the US system pays and nationalized systems don't is actually legitimate -- it pays for medical R&D. If we just regulated prices like other countries then that money disappears -- which is fairer, but that doesn't mean it wouldn't cost lives. Other countries have lower costs because they're ripping us off by not paying an equal share. Unless you can convince them to pay more, we can't eliminate that cost without eliminating the research it pays for.
Moreover, there is no question that parts of the US system are terrible -- especially the insurance companies and the amount of overhead and inefficiency that comes from using "insurance" to pay for non-catastrophic care. But it should be possible (politics and corruption notwithstanding) to change that part of the system without nationalizing the whole thing.
Because national healthcare has its own problems. From your link:
> In Japan, if spending in a specific area seems to be growing faster than projected, they lower fees for that area.
That's the bureaucratic solution. It absolutely works to keep prices down. As long as you don't mind that it implies responding to demand by spreading the existing resources thinner without regard to how that affects outcomes.
There is a reason the US has a worse average but a better median. There have to be ways to reduce costs and help the bottom 20% without hurting the middle -- and that's the only thing that will pass anyway, because you can't get 50% of the votes with something that will reduce the quality of care for the other 80% of people.
The density argument doesn't make sense. If that were true, New Jersey would have cheap healthcare on par with "those countries" that have similar population densities. New Jersey would also have cheap, super-fast broadband and a robust statewide public transportation system, other things that people claim the U.S. simply can't do because population density.
For example, one of the strongest indicators of high healthcare costs is having a Democratic majority in the local legislature, which tends to correlate with density and cancel out the benefit. If you look at the red states you can clearly see the effect of density -- the higher density southern red states (Texas/Georgia/Virginia/Carolinas) have lower healthcare costs than the lower density northern red states (Alaska/Wyoming/Nebraska/Dakotas).
Well, did they go there because they were actually ill? If so, the experiment did in fact improve public health.
> "Medicaid coverage increases emergency department use, both overall and for a broad range of types of visits, conditions, and subpopulations," says Amy Finkelstein, an economics professor at MIT and one of the authors of the study.
> "Including visits for conditions that may be most readily treatable in primary care settings."
[0] http://www.npr.org/sections/health-shots/2014/01/02/25912808...
That's just engrained practice. People used to go to the ER instead of a regular physician, now they continue what they always did. You ask yourself why the hospital doesn't set up a regular practice on the premises and has triage send patients there.
More seriously, I suspect routing routine patients to lower-cost settings would put ERs more in the red under our current system.
In Texas, they are legally prohibited from doing so. They would have to send you to a physically-separate location, even if said location was still in the hospital's parent network.
We could at least have a little compromise by making health care more tiered so that citizens, payers and people with insurance receive better health care than others. Make a list of services that will only be provided to payers and automatically push non-payers to the back of the queue.
Additionally, we already had that system in place, it was called "lifetime limits" and it was typically $1-2m on the best healthcare plans.
I'm amazed sometimes the things people say here.
Ie: I broke my toe and I have insurance, so I get ER treatment, but that guy who has no insurance and is internally bleeding to death from a street stabbing (and is hispanic, doesn't have insurance and maybe isn't american?) is pushed behind me in line. That is the real life scenario that at least one person is advocating here.
I think as the governments become more starved (not made more efficient by reducing costs, starved by simply cutting funding without optimizing it logically) that important government services will have to replaced with tiered private companies. As regulations are removed, the same thing occurs.
What if a speed of ambulance was built into your insurance? How do you know what response time is right for you and your family (as it will be framed)?
It's impossible for that not to be the case. It's even the case in countries with single payer, because rich people who live there and don't want to wait for an appointment or want something that isn't covered will just go to a country that can give them what they want and open their wallet. Even without leaving the country, they can hire private nurses and so on when they aren't covered by the national health system.
Moreover, why is this supposed to be a problem? "Money buys things" is the purpose of money.
There are things a rational national health system wouldn't pay for because they aren't economical, but a rich person would buy for themselves for much the same reasons they buy a Tesla instead of a Dodge. Which means they have a safer car because they have more money. Should we prohibit expensive safer cars because poor people can't afford them?
Although I would prefer to concentrate on the 10s of millions of non-citizens and illegal aliens who receive tax payer funded health care.
You're gonna have to provide a citation for that claim, there.
I feel like I should remind you here that many non-citizens are actually tax-payers. Taxes are paid in many different ways, but let's forget about that here for a second and realize that many non-citizens actually come here legally to work.
A blanket statement like that really doesn't mean anything. Same arguments were given about dreamers using tax-payer money, without realizing many of them actually are tax-payers as well.
Shouldn't triage take into account who is the most profitable so wealthy people can go to the front of the line where they deserve to be?
I mean really, why should my undocumented nanny, house keeper and gardeners be entitled to the same health care that I am? [Of course, I don't pay them enough to buy health insurance but that's their problem.]
As @gselevator tweeted "I never give money to homeless people. I can't reward failure in good conscience."
(This is sarcasm in case it isn't obvious.)
It totally reads like the kind of libertarian/dude-bro nonsense that has invaded tech.
I'd be wary of reusing text like this in other areas, because until I skipped ahead to "this is sarcasm" I was like "oh here we go again"
The next question would be: how many of the people that ended up on the ER could actually afford healthcare? And why didnt they have/use it?
It seems like it doesn't take any more resources to take care of me next week then it does 6 weeks later.
Instead, the 6 weeks is a result of 1) the number of people who wish to get appointments, 2) the time that each person spends, and 3) the number of people who can be treated at a time:
MeanResponseTime = MeanNumberInSystem / MeanThroughput
[0] https://en.wikipedia.org/wiki/Little%27s_law#Finding_respons...
If people call for an appointment, and find they have openings this afternoon and tomorrow morning, they'll be more likely to go to the doctor. If they find that the earliest appointments are 12 weeks out (as I did when trying to schedule a physical before a recent trip to Asia - ended up skipping the appointment), they're going to go elsewhere.
If you're viewing the queue as a sort of plumbing system, this can be approximated as backpressure.
Although anecdotal, multiple family members who are health care providers in the ER (Nurse, PA, Doctor) it's more often than not far from an emergency ailment. This creates a scary supply and demand scenario.
1 - Any time a condition/illness causes bad nausea/vomiting, the urgent care will send you to an ER to get IV meds and fluids, which they can't do. You probably don't need a full ER, but that's the only place to go. This must be fairly common during flu season, and a huge waste of resources. A startup idea could be an Uber for off-hour home visits. If all you need is IV fluids, check some vitals, keep you comfortable to ride-out a nasty virus, surely it's in everyone's interest to have a quick visit by a nurse/PA, possibly MD.
2 - Pain management. If you have a relatively new illness or injury that requires stronger medications to manage the pain, you have no choice but to go to an ER, or perhaps be admitted to a hospital (which is even more expensive). I can't say if over a longer period of time, for a chronic case, there are better options that eventually get worked out. But 2 months into such an issue with a family member, and going to the ER was frustratingly the only option.
3 - Chest pain. Yes, it could be a heart attack, so maybe an ER is the best place to go. You will get triage pretty quickly with an EKG, and some basic vitals, but you're still stuck there for hours if it's a false alarm (I'm guessing quite often). There's got to be a better way.
For that reason, I visited ER twice that week, and was diagnosed with some mild stomach issue and stress. Every single test they ran gave negative result. It's a huge waste of time for me, and I feel very guilty for wasting ER resources (especially as an immigrant). There has got to be a better way.
Edit: I was very lucky to be covered under school-mandated health insurance, and I don't think you could live comfortably in the U.S. without having one.
That's the missing equation - that for the uninsured, the only remaining medical option is the ER.
Comparatively, Emergency care/Ambulances are available almost everywhere through 911 AND take most of the mind space around urgent issues.
Finally, Urgent Care centers are not equipped to handle lots of things like broken bones etc. They just refer you to an emergency center instead.
Maybe we should just put the Urgent Care facility in the same building as the ER and then route people appropriately when they show up.
My girlfriend went to an Urgent Care with a stomach bug. They asked if she had any abdominal pain, and she said yes. That was a flag for them to say "We can't handle you because abdominal pain is a flag for possible appendicitus so you have to go to the Emergency Room now."
There was no way she had appendicitus. She just needed an antibiotic. But you follow the hospital's advice, and stepped into the ER and suddenly was charged $5,000 for useless tests and had to stay there for 6 hours.
https://data.oecd.org/healthres/health-spending.htm implies that the US is spending considerably more (~ double the OECD average) per capita. ER visits could certainly explain some of that.
The crux is making it easier for consumers to get health care information, putting more choices in the hands of the patient, and creating a mechanism to encourage price sensitivity even if people don't pay for their care directly.
We're mired in this current system with no rationing, low accountability, and rentiers sucking cash with the Government's approval and leftist protection against any reduction to the cashflow. Look at the yelps ushered by leftists when Trump stopped giving insurers free money - many of them bemoaned the loss of corporate welfare.
The crux is making it easier for consumers to get health care information, putting more choices in the hands of the patient, and creating a mechanism to encourage price sensitivity even if people don't pay for their care directly.
failing that, let them rely on charity.
It's within the first two pages, look for the paragraph that starts with this
5. Said charges under (3) and (4) will, when submitted to Treasury
thanks?
"The high-income group, with average household income greater than $70,000, is the standard to which all others are compared... 30 percent of the population in the $30,001–$50,000 range ...have 59 percent more mortality than is true of the richest group."
[0]: http://content.healthaffairs.org/content/21/2/31/F2.expansio...
Source: http://content.healthaffairs.org/content/21/2/31.full
It's not half of US medical visits to any kind of medical care that are at emergency rooms. It is half of US medical visits to hospitals that are at emergency rooms.
That's a big difference. Among other things, they are not including visits to your family physician. If they included ordinary visits to your doctor outside of the hospital, then emergency rooms visits would be a much lower percentage.
Looking at the original abstract:
http://journals.sagepub.com/doi/10.1177/0020731417734498
It says, "Our study aimed to determine the contribution of EDs to the health care received by Americans between 1996 and 2010 and to compare it with the contribution of outpatient and inpatient services using National Ambulatory Medical Care Survey and National Hospital Discharge Survey databases."
They are comparing emergency visits to other kinds of hospital visits.
Perhaps we ought to reverse the incentive.
Well ... yeah.
Even beyond the family physician, there are many specialists that are affiliated with hospitals but see patients in their offices, outside of the hospital registration process.
In fact, those specialists often have offices in the hospital or in buildings attached to the hospital.