
High-Deductible Health Policies Linked to Delayed Diagnosis and Treatment - Deinos
https://www.npr.org/sections/health-shots/2019/04/18/713887452/high-deductible-health-policies-linked-to-delayed-diagnosis-and-treatment
======
CptFribble
I think most people around here know that our healthcare payment structure is
totally whack. However, we're not the people who need to know this.

Try showing an NPR article about universal healthcare to Joe USA. I guarantee
you'll get one or all of the following responses:

1: I don't want my taxes to go up

2: I don't want to pay for illegals to go to the doctor for free

3: My insurance will get worse

4: I like my doctor, I don't want to be forced to go to a worse one

5: I don't want the government deciding when I go to the doctor

6: I don't want to wait six months for a doctor appointment

7: NPR has a liberal agenda

Many of my family and extended social circles are quite conservative (in the
USA sense) because of how I was brought up. I have heard all of these and more
every time the concept of universal healthcare is brought up.

Most of the reasoning I hear is not based on facts, but on emotionally
misleading arguments from the network of memes and punditry where they get
their info. And when they vote, they vote for people who oppose universal
healthcare on these fallacious bases.

How do you convince someone like this that universal healthcare is better for
all of us?

~~~
rossenberg79
I don’t believe in universal healthcare, and none of these approaches do much
to convince me.

I’m in agreement that the current situation is hot garbage, and it’s shitty
for a lot of people. However, my insurance now is good enough for me and my
family. Sure, it’d be nice if it was cheaper, but whatever. As I get older I
find I can’t be bothered to lay awake at night worrying how everyone in the
country gets healthcare anymore. I’ve simply accepted that this is the world
we’ve been dealt and everyone needs to find their own way to survive.

My main concerns are 3,4,5,6. I don’t see them as “fallacious”, I think it’s
naive to assume universal healthcare will work exactly as planned with no
unforeseen consequences, and I’m generally suspicious of people who do not
list the risks along with the benefits.

~~~
magicalhippo
FWIW, some views from Norway, which has universal healthcare.

3: Don't need health insurance so I'd say that's better.

4: We can chose our own primary doctor from the pool of available GPs.
Available just means that some GPs have too many patients on their list
already and don't have any slots available. You can switch primary GP once a
month (IIRC). I switched a few times until I found one which I liked. Repeated
the process when I moved.

5: I can see my GP whenever I feel like it, just need to set up an
appointment. If you mean to see a specialist then yeah, I'd need my GP to
refer me. Sometimes this can feel a bit unnecessary but mostly it's not a big
issue IMHO.

6: If my GP doesn't have time for me, I'd just switch and find one who does.

~~~
sanderjd
> _3: Don 't need health insurance so I'd say that's better._

You do have health insurance, it's just provided by the government with
premiums paid through taxes. When people express the concern that their
insurance would get worse, they mean that the insurance provided by the
government would be worse than what they currently have. There are a number of
different things that people think make plans worse or better, which is a
major contributor to the difficulty in having a clear discussion about this.

~~~
magicalhippo
> You do have health insurance, it's just provided by the government with
> premiums paid through taxes.

Yes, I had a line about being taxed quite heavily but deleted it for reasons
I've forgotten, and I missed updating point 3.

I don't need to worry about my insurance though, what it covers etc.

~~~
sanderjd
I mean, you _do_ have to worry about that. It's just that you're happy with
what it covers, so you don't worry about it. Despite all the well known awful
problems we have, most people in the US actual feel the same about our plans
as you do about yours. I don't have to worry about what my insurance covers
because it is a good plan, and if it becomes worse, I can look for a better
one. This is true for most people in the US - mostly those of us fortunate
enough to have good employer sponsored plans - it just isn't true for enough
of us in a lot of peoples' opinion (which I share).

One thing I'm way more afraid of with a single payer system (but not
necessarily all universal coverage systems) is that if the coverage became
worse, I would have no recourse; it would be a monopoly, I wouldn't be able to
look for a better competitor. Even worse, it would be a monopoly run by a
political bureaucracy, so coverage decisions could become political. For
example, coverage for birth control is a very political topic here. I'm
certain that the first incarnation of a single payer system would cover that,
because it would be set up by the politicians who favor it, but once the
system is enshrined, whoever is in power would be able to change it however
they think best. Coverage policy could easily become a political football.

------
PaulHoule
These are going to be recognized as a policy disaster.

There are many cases where a somewhat expensive treatment saves a very
expensive hospitalization.

For instance, a steroid inhaler for asthma costs about $200 a month, maybe you
have two $200 specialist visits a year. So for $2800 a year (not covered by
high-deductible insurance) you can probably be symptom free or you can take
your chances and have an exacerbation and a $28,000 hospitalization (which
insurance will pay some of after the deductible)

Docs hate them too.

With real insurance, you have maybe a $20 copay you pay at time of service and
they know they are going to get paid by the insurance.

With fake insurance, they don't know what you are going to pay until months
later when the insurance gets around to telling them. Then you get a bill that
says you owe $291.44 for some unspecified service you got 6 to 18 months ago.

(They can't tell you what it was because that would violate your privacy)

Needless to say they have a big accounts receivable this way, many people
don't pay or they pay late (e.g. a few months after getting a bill they don't
understand as well as something that says "THIS IS NOT A BILL" they don't
understand). This is not good for their finances or their state of mind.

In theory high-deductible plans might lead you to shop around between
providers to get a better price but in practice nobody can or will tell you
what things costs and it doesn't work.

It's a perfect example of the neoliberal mind at work.

~~~
apazzolini
While not applicable for everyone (such as your asthma inhaler example), HDHPs
aren't bad for people who don't have regular health expenditures. I like my
HDHP for two main reasons:

\- Regular annual checkups are still free

\- You get access to an HSA account, which is effectively the most tax-
advantaged retirement account available. You can deposit income pre-tax,
invest the balance (minus a few hundred), and withdraw tax-free as well for
either health expenses (at any time) or for any purpose (after 65).

~~~
NotSammyHagar
Why I was 25 I hardly ever got sick. Now I'm double that age, and I'm in good
shape but eventually something will happen. When I was 25, I could have had a
hdhp then, but I was a super poor grad student and got whatever my university
offered, a regular plan. Eventually I got a real job, there was no hdhp
offered and I had regular insurance. The thing was, by being part of a larger
pool, I was helping make insurance reasonable for everyone. That's as it
should be. I do think ubiquitous health insurance that _everyone_ has will
save money in the end, and it's a humane necessity.

------
sologoub
This is starting to feel like the mortgage crisis again - specialty tools that
are not in themselves bad, are being misused to bolster affordability and in
the process create very bad financial situation.

The HDHP + HSA are great for those that can afford them AND are in good health
overall. Good employers also add to your HSA each year to help with the
initial costs.

The HSA is a lot better than the FSA, which creates bad incentives on use it
or lose it money.

The problem becomes when HDHP is used without a well funded HSA and with
insufficient income to handle the deductible, together with health problems.

~~~
sokoloff
We took a HDHP just in order to qualify for the HSA. It probably doesn't save
us money on the health-care side, but the HSA as stealth additional retirement
account more than makes up for us.

[https://www.madfientist.com/ultimate-retirement-
account/](https://www.madfientist.com/ultimate-retirement-account/)

~~~
assblaster
I do as well.

The best part of the HSA is that you can save your receipts and reimburse for
those expenses 30 years later instead of right away so that you can pay with
gains rather than principal.

------
olefoo
The health care system in this country is a crime. It is structured to take
advantage of people at their weakest and most helpless. We spend 3 times as
much per capita as most other industrialized nations and get worse outcomes
overall.

~~~
xenospn
That is correct. I am originally from Israel and moved to California 7 years
ago. I'm very healthy but on the rarest of occasions, when I do need to get
SOMETHING done, it has proven to be an absolute nightmare, and I always walk
away feeling like I've been scammed.

~~~
komali2
The one time you aren't being scammed is when you get something done and
actually get to bill the insurance company.

Paying monthly installments on your insurance plan, only to have to pay for
your healthcare costs anyway (first the deductible, then this new maximum out
of pocket they added to me this year), that's the scam.

~~~
beenBoutIT
In reality, if you're spending ANY money on healthcare in the US you're
getting scammed. The healthcare you'll find in Israel and Europe is the modern
standard of care and the US is on the opposite side of the spectrum with our
corrupt for-profit "healthcare" industry. We pay more for generic crap
(generic only has to be 80% as effective as brand) than modern countries pay
for 'Made in USA' brand names.

~~~
m0zg
One thing people miss is, we're paying our doctors _several times_ as much. If
that doesn't change (and nobody wants the doctors to earn as much as they do
in Europe: there just won't be any doctors), there's really no way to achieve
the same cost structure without replacing doctors with something like machine
learning in a lot of capacities (radiology/imaging most immediately, other
diagnostics in the longer term).

~~~
komali2
> (and nobody wants the doctors to earn as much as they do in Europe: there
> just won't be any doctors),

Why are there doctors in Europe then?

As I've read, it doesn't seem that the cost of healthcare is dramatically
higher in the USA because we pay our doctors more, it's because of the
insurance industry, and how much money people have to spend figuring it out
(hospitals have to have staff specifically to deal with it, as their whole
job).

~~~
m0zg
Because coming to the US is a hassle and we'd force them to basically re-
qualify to be allowed to practice. Some European doctors do move here and go
through the hassle nevertheless.

Regarding insurance, I believe since ACA was enacted there's now a limit on
how much profit an insurance company can make, as a percentage of the money
they pass through. I'm not a specialist in this field, but this seems to have
only made matters worse.

~~~
komali2
>Because coming to the US is a hassle

Ok, to be clear, you seem to be suggesting that everyone would live in the USA
by default if they could, and the only thing stopping them is inconvenient
immigration and the cost of a plane ticket?

I feel like I must be misunderstanding you because it seems a bit silly.

~~~
m0zg

      >> you seem to be suggesting that everyone would 
      >> live in the USA by default if they could
    

You're not arguing in good faith. Goodbye.

~~~
komali2
??? I'm trying to, hence my attempt to clarify. Could you please help me
understand what you were saying? I'm trying to read it as anything but how
I've restated it, but I genuinely can't.

How about this - if America didn't exist, and doctors got paid what they got
paid in Europe right now, why are there doctors in Europe?

~~~
beenBoutIT
European doctors aren't in medicine to get rich. A decent number of doctors in
the US went into medicine primarily because of the pay.

~~~
komali2
So isn't it reasonable to assume we will still have doctors if the pay is at
the level of European doctors then?

------
wsdfsayy
This shouldn't be surprising. If you're on an employer-based healthcare plan,
a HDHP only makes sense if you're young, healthy, have no dependents, don't
take expensive medication, _and_ your employer pays most of the annual cap
into your linked HSA.

I fit most of those checkboxes, but I take PrEP (preventative HIV med) that is
something like $1500/month before deductible, and the math for HDHP vs
traditional plan does not check out in that case at all.

~~~
lotsofpulp
If the difference between the premiums for a non HDHP and the HDHP deductible
is not too big, I can very well see it being worth it to go HDHP just to take
advantage of the triple tax advantage of HSA.

Pay for medical care/medicine with after tax, save the receipts, and let the
HSA contribution with pre tax money grow tax free in a Fidelity HSA (since
it’s free) and then withdraw it whenever you want, and just pay yourself
whenever you need the money.

------
nicodjimenez
Obamacare is unfortunately a band aid solution and does nothing to address the
fundamental issues:

1) complete lack of price transparency, which means virtually no price
competition between clinics / doctors 2) artificially low supply of doctors to
jack up prices 3) corrupt regulation to prevent consumer health startups from
existing

Fixing these issues is going to take a lot more than just taxing people for
not buying high deductible health insurance.

There's no fundamental reason why most doctors should get paid more than
airplane mechanics for example. Either way if they mess up, people die.

------
uberduber
I got an individual HDHP as soon as I turned 18 in 2004. Shopping around on
these plans is not easy, I'm really the only one to do it. I thought it would
get easier as more people got HDHPs, it got a little bit better over the years
and then drastically went downhill after the ACA. Two main reasons: reduced
competition, and our bizarro culture where no one blinks at an $800 surprise
bill.

I used to have a couple imaging facilities that I went to because their rates
were low. In the past few years they have all been bought up by some sort of
conglomerate and prices have gone up. It’s not advertised, so I literally have
to call the place, talk to the back office and find out if they’ve been
bought. So last year I go to the one place that hasn’t been bought, rates were
good, I go this year and the bill was a surprise. Even my blood test rates
have gone up this year, I’ve asked several doctors and they’re like “Yeah,
it’s pretty much Quest or Labcorp now.” So my rule now is, if the back office
has no clue what they're doing, they will likely be cheap, and they will
likely either get bought up or go out of business.

Many years ago when I’d go to the doctor I think I was literally the only one
with an HDHP, and the allowable amount would come out to $200, and they’d go
“Oh, that’s not right. How about $60?” And just take $60 from me and call it a
day. Now when I ask “Will this test cost me more than $200?” No one has an
answer or seems to care like we are in some crazy bureaucracy.

~~~
winter_blue
I was on high-deductible plan a couple of years ago, and went in for an
allergy test. After the test, I got a bill for $750 ish. Insane. This was in
November as well, so two months later the deductible would reset in 2 months.
In the same year I had a whole array of expensive dental work done, and I
almost exhausted my HSA. I swore off high-deductible plans ever since then.
Even though I'd selected a HDHP at the beginning of open enrollment (in Nov)
that year, I was able to call HR in December and switch me to a normal PPO
plan (which just had copays).

------
viburnum
That’s the point, people are supposed to not get treatment. If you wanted
people to get the treatment they need, then it would be free.

------
javagram
I’ve had a HSA+HDHP for years.

I’ve always contributed the annual maximum into the HSA so there was never a
question for me of running out of money to pay for care, and it hasn’t held me
back from seeking medical care or treatment.

However, it’s perfectly possible for someone to elect the HDHP and not
contribute to their HSA, in which case you could be facing a $3000 or higher
bill without the money to pay for it. It seems like this is the case described
in the article.

With a fully funded HSA I almost feel like I have the opposite problem, which
is I don’t feel a need to attempt to shop around and compare prices.

In general it feels like the HSA/HDCP experiment has failed although I’ll keep
using it for as long as it’s offered, as I like the ability to build up my
savings every year in the HSA and eventually use it as a second retirement
account unless I have a huge medical problem in the future.

~~~
conanbatt
HDHP are growing a lot, so its succeeded. PPO plans are garbage. Way too
expensive and has terrible utilization incentives.

------
tomohawk
When selecting from health insurance options, I only ever consider HSA plans,
which typically have large deductables.

Why?

The US has the best health CARE in the world, but with a crappy health
insurance system. The health insurance has been regulated to a hot mess by
cronies and politicians that is slowly destroying the care system.

An HSA gives you more control of your care.

Rationing care is not the answer to solve the insurance problems. I'm not
interested in waiting for long periods of time for rationed care, such as what
is seen in Canada.

[https://www.fraserinstitute.org/studies/waiting-your-turn-
wa...](https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-
for-health-care-in-canada-2017)

For all its faults, at least I can get an MRI within a day or two, and can see
a specialist within a day or two. That's way better than waiting on rationed
care.

------
asdf333
i hope this is a transitional cost. i am on the fairly liberal end of things
but was hoping high deductible plans would force prices lower by getting
consumers involved while still protecting against catastrophic events.

and we are starting to see pressure on drug companies and medical care (epic
pen issue for example) as consumers push for reform now that they are feeling
it in their pocketbooks more directly.

~~~
DubiousPusher
> but was hoping high deductible plans would force prices lower by getting
> consumers involved

Part of the problem here is a lack of price transparency. That's what's
stopping consumer choice driving any price reduction. It's very difficult to
shop medical expenses. In the end it seems like the main choice they give you
is really either to do it now or delay.

~~~
LarryDarrell
Not to mention the narrowing of In-Network providers. I can't shop around if
my Network has already been reduced to the smallest size possible.

------
bryan11
Switching from a co-pay based insurance to an HDHP + HSA was a big change. My
deductible is quite high, so all normal, non-catastrophic medical costs are
paid for without insurance.

A doctor visit starts at $139 and may be from $300 to $500 depending on the
diagnosis. One cannot determine the cost in advance. Any lab work is extra. Is
it worth $1000 every year to have a doctor do standard blood tests?

Like anything that suddenly becomes very expensive, it makes one look at
things differently and question whether they are necessary. Some people put
off doctor visits longer until things seem unbearable. Some research online
and try to self medicate with over the counter things.

------
40acres
I'm exhibit A. I signed up for an HDHP because I didn't want to pay a monthly
premium and thought and HSA sounded like a great way to save for health
expenses. I had a bout of rhabdomyolysis after pushing myself while at the
gym, after doing some research and learning that it probably wasn't life
threatening I decided to wait it out and self treat instead of going to the
ER.

------
jhawk28
People don't like HDHP, but they are the only type of insurance that puts
downward pressure on prices. the only alternative is to regulate.

~~~
maxxxxx
In what way are they putting downward price pressure? every tried to get
prices for a treatment so you can pick a cheaper provider? It's close to
impossible to get any numbers.

------
psim1
I have found that by paying the same amount as the premium of the PPO into my
HSA that I come out even, if I end up spending the whole deductible, or ahead
(i.e. building savings), if I don't. In other words, I don't see any
disadvantage to HDHP+HSA vs. PPO plan.

------
snr
A little off track rant but the tax and health policies of USA are super
freaking unbelievable. Why on Earth can one not be eligible for a HSA when
they don't have a HDHP? The healthcare is screwed up. The least you could let
people do is use their pre tax monies for the health treatments.

And don't even get me started on FSA and forfeiture. That's MY money. What the
hell do you mean the amount is forfitted?

Apologies for my language. The policies are making me go crazy.

------
ykevinator
The gullible have become emboldened so despite the headline, they confidently
believe there is no problem.

