I'm a Brit and America, your health care system is torturing me | Hacker News Reader

I'm a Brit and America, your health care system is torturing me

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47 pointsOsiris69 comments

I favor nationalized health insurance, but I worry American idealism would screw up implementation. The British are aggressive about rationing care. They aim to pay around 20-30,000 pounds per quality adjusted life year: https://www.bbc.com/news/health-28983924

There was an article on HN the other day that talked about how much debt a woman had incurred for her husband’s cancer treatment after she hit her insurer’s lifetime limit. But it turns out that in the UK, the expensive of that course of treatment compared to prospects would have been far above what NHS would have been willing to pay.

If you have socialized care, you need to ration it, ideally focusing on maximizing QALYs for younger individuals with years of productive life left. I fear our political system in the US wouldn’t let us do that.

EDIT: Here is the article: https://www.npr.org/sections/health-shots/2017/08/10/5425892.... The insurance policy's lifetime limit was $500,000, or about 400,000 pounds. Even if we assume British healthcare costs half as much, under NHS's policies, the expected benefit of treatment would have to be 6 QALYs for NHS to have paid even as much as the U.S. insurance company paid. But it was a rare, aggressive cancer and the lady's husband died in less than two.

Another problem is that for a variety of reasons, some of them structural, Americans consume significantly more medical services (diagnostics, procedures, visits) than Europeans do, without improved outcomes. There are fundamental inefficiencies in our system --- for instance, incentives have led to the creation of lots of small hospitals that see poor utilization --- that lead to this, and will be baked into any single-payer system we devise.

This concerns me enough that I oppose nationalized health insurance. I think the status quo ante of the ACA was intolerable, and that the system needs dramatic improvements (high on my list would be price transparency regulations), but that the core problem we have in the US is not that health care isn't universal, but that we pay too much for it, and baking that quietly into our taxes is an alarming proposition.

> (high on my list would be price transparency regulations)

Why didn't the republicans do that over the past two years in the US? It seems like it would be great for the free market, and also encourage competition. Or do they believe in large company profit "protectionism"?

I don't know, except to say that national health policy has become a political football. I don't think there's an ideological reason for the decisions Congress has made; the system we have now was the Republican's proposed system in the 1990s (and was even a policy plank the the 1996 Republican Platform).

It's very easy to explain Republican opposition to the ACA. The 2016 election has made it clear that the GOP is motivated not by outcomes, not even by ideology (the current GOP, driven as it is by one person, has no coherent ideology), but by tribalism. Obama was and still is considered an enemy who cannot be allowed to score a victory at any cost, and so Republicans had to oppose the ACA.

I know that this take is likely to be viewed as extremely uncharitable to Republicans, but there really is no other logical way I can see to explain the party's anti-ACA plank.

(I think it's actually quite counterproductive to the conservative movement, because by abandoning ideology in favor of naked partisanship the GOP has guaranteed that Democrats will never give them a seat at the table when health care reform comes up again while Dems are in power. As a liberal, I couldn't care less, of course, but I can't help but note the irony...)

That's an argument I'm familiar with and sympathetic to, but not something I'd necessarily argue in mixed company, which is what I think of HN as. I don't understand the current coherent argument the GOP has regarding health care but I'm open to there being an ostensible argument and would only ask that Republicans recognize that whatever the new argument is, it's distinct from the original argument, which is that we should have a system that looks basically exactly like the ACA.

This is what I don't understand either. I understand the desire to cut medicaid to reduce taxes and the size of government argument. But weren't there free market incentives they could have done as well?

Here's one: tax cuts to insurance companies based upon the number of people they insure over time, to help offset the cost of insuring sick people.

This seems like a no-brainer republican solution, which probably would have gotten a fair number of democrats on board.

1.) Insurance companies don't have infinite money - they ration as well. See point 8.4 in https://slatestarcodex.com/2017/02/22/repost-the-non-liberta...

2.) If you want private healthcare in the UK, you can still get it: https://en.wikipedia.org/wiki/Private_medicine_in_the_United... Public healthcare doesn't mean private healthcare is illegal - why would you think that?

Meanwhile, here in the UK the NHS - weaponised by the left and virtually above criticism/reform as a consequence - tortures people by making them wait months/years for treatment due to rationing of care, this rationing in no small part being due to the fact that care is free at the point of delivery, which leads some people to abuse the service. Even a token £10 charge for GP visits, for example (subsidised for the genuinely incapable of paying) - similar to the Netherlands - would likely deter many of the unnecessary visits, and raise desperately needed revenue. I would gladly pay. But any/all genuine reform is blocked by the left raising the spectre of privatisation. So let's not pretend we have the all the answers here in the UK.

Here in the Netherlands we are not charged for visiting the GP (thanks Theme Hospital for learning me this term). Only for specialist treatments or medicine after diagnose you pay either a deductible if it falls within base insurance or 'normal' prices if you're not additionally insured.

This is so nobody is discouraged from visiting the doctor for help.

> But any/all genuine reform is blocked by the left raising the spectre of privatisation

I don't know if you didn't notice, but the Conservatives have been in power since 2010, and until recently have had majorities. They could have introduced the charge you suggest, but haven't. This isn't a left/right issue. Please don't turn this into some left v right brawl.

This is more of a sidenote, but after having way, way more experience in healthcare system over the past few years, I thought I would share my experience.

The Affordable Care act made some big changes in health insurance. Unfortunately, making it "affordable" was not one of the things.

But, if you do have money, you have the option now to have absolutely great health care.

For about $1300 a month, you can cover a family of 3 in california. That amount is less if you qualify for subsidies. And that is not a budget option. This is a premium silver PPO from a large provider. All your normal medical needs are covered with copays. $40 for doctor visits. $80 for specialists and $350 for an E.R. visit. Your max out of pocket is $7500 per person or $15k total. So $30,600 a year is your absolute worst case maximum that you would have to pay if everyone in the family had serious medical issues in one year.

Now, I agree, that's expensive. But we are on a plan like this and it is very good coverage (and it's likely not much more than companies pay for their employee plans). While sometimes navigating everything has been a beurocratic nightmare, it has never denied us coverage and almost every doctor we have come across is in network. It also pays about $600 a month (after $80 in copays) for our regular, ongoing prescriptions.

It also covered the $600 a month eyedrop Rx I needed for about a year for dry eyes.

The quality of care is top notch and we have never had to choose anything less than the absolute best when it comes to treatment.

Anyway, my point is, American quality of care is some of the best in the world. If not the best... If you have money.

In 2017, the median income of households in the US was 61'000 $.

Meaning half the population has to pay half their income (maximum) into this healthcare plan. And 61'000$ income isn't being dirt poor either. In some economic models this is the lower middle class in terms of income.

For people who only graduate high school and no college, this is 80% of their income. If they go to some college about 70% (14'000$ left of the income). This group makes up about 30 to 40% of the US population.

In my own country, I would pay 350€ a month for a 60'000€ yearly income. The equivalent of an ER visit copay for you and it covers all my medical needs for a month.

With a multi-person household and $60k income, you would qualify for subsidies to reduce the premiums and out of pocket costs.

The key idea in the ACA that addresses this problem is subsidies: you get tax credits and (ostensibly) CSRs to offset the cost of health insurance if you're within some multiple of the Federal poverty line. Unfortunately, this is exactly the part of the system Congressional opponents of the ACA have taken direct aim at.

The ACA reduced the rate of growth in health insurance premiums, but health insurance premiums continue to grow and have been for decades --- spiraling health care costs were a part of the Republican Party platform... in 1980.

Guaranteed issue, community-rated health insurance is a necessity for a private health care system, and the ACA brought those badly-needed features here. But the big problem with US health care is simply that it costs too damn much to stay healthy, and those problems are structural more than they are a function of how we fund the system.

Saying the ACA reduced the rate of growth in healthcare spending is arguable. The last time I looked at this there was indeed a reduction in the rate of growth by my understanding is that it predated the ACA by several years.

The most interesting thing I've seen about health care inflation is what it looks like in the U.S.A. vs. the other developed countries. The answer is not that different. There was a huge increase in the 80's but after that the growth rate of the U.S. is somewhere in the middle.

But aren't those structural problems directly caused by the way we fund the system?

No, I don't think that's even partially true. Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with. Medicare has lower administration costs, but those costs are still higher than administration elsewhere in the world, and administration is not actually where most of our dollars go.

So maybe I don't know what you mean by structural problems. I assumed you meant agency problems, administrative costs, medical professional pay, liability costs, over care & end of life care.

All of which are directly impacted by how we fund the system.

Two examples of structural problems with our health care systems:

1. We lead the world in transitioning from inpatient to outpatient care; for instance, I read a source last night that said the majority of hernia repairs in the NHS were inpatient, and the overwhelming majority of them in the US were outpatient. That's good, but an unintended consequence of it is that it's easier to route a patient to a surgical procedure if it's done outpatient, and as a consequence US patients get a lot more of these procedures, some of them (cardiac stents being a recent well-publicized example) of dubious utility. Our relative overconsumption of services doesn't lead to better outcomes, and thus represents misallocation.

2. Our health provider systems are more decentralized, delivered in smaller clinics and hospitals. Our hospitals generally, nationwide, have poor utilization. Not only do we therefore overspend on plant and salary costs (which we do, relative to Europe) but coupled with our price transparency problems we end up with the situation Atul Gawande described a year or two back, when he noted the insane difference in prices for an MRI at different imaging centers in a small region of (iirc) Texas.

Our system right now isn't good and some of it (but by no means all of it) is related to how we regulate the way it's funded. But Medicare overspends on many of the same things. The structural problems will need to be corrected no matter how we design the rest of the system.

Ultimately I think the problem in the US is a sort of perfect storm of badnesses.

(Good sources: Kauffman's health cost explorer, the McKinsey report, the Health Care Cost Institute annual breakdowns).

Both of those are classic examples of the outcomes being directly related to how we fund our medical care.

In the first instance it's a tension between the providers trying to maximize service, insurers trying to minimize risk and the user having little agency in the outcome.

The second example is a straight up agency problem.

None of that changes the argument, it is a perfect storm of badness and even if nationalized healthcare was politically feasible it wouldn't fix all of these issues.

I just want to get to the point where my insurance doesn't come from my employer...

There are a bunch of ways to rebut that argument. First, you can look at private systems that don't have these problems (ie: all the rest of the private systems). Second, you can note that Medicare, our single-payer system, interacts with the same structurally inefficient provider system. And, of course, if we switch to single-payer tomorrow, we're still going to be doing most care on an outpatient basis (because we should), and are still as a result going to be overprescribing procedures to patients.

> Second, you can note that Medicare, our single-payer system,

Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.

Fair enough. Consider my rebuttal so revised.

Let me expand on that: Medicare has recognized the problems you mentioned and has, fairly recently, begun directing efforts through payment system at the first broad class (inefficient interventions) through adoption of a variety of quality-incentive payment systems. But those aren't going to be as broadly effective, even for Medicare fee-for-service patients, as they could be if delivery systems and practice is shaped by conflicting incentives from different payers (who may be involved in covering some of the same claims, because coordination of benefits is a real thing, and even when they aren't for the same claims, will often over time be for treatment of the same patient.)

The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others).

As for the private options do any of them have the weird employer provided health care indirection?

I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.

Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.

Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.

I'd probably report I liked my car insurance if it included a twice a year detailing and paid for my lyft rides from the bar. Especially if the real cost of it was hidden from me. That is to say, the consumer of health care being unable to accurately judge the quality and efficiency of the funding of that care is at the heart of the problems with the market based approach to health care funding.

The fact that one of the major players in the funding space have an intermediary as a customer instead of the health care recipient is a further distortion of the market.

Imagine if we got our car insurance the way we get our health insurance. What impact would that have on efficiency of that industry?

Our health insurance system is inefficient, and some of that inefficiency does come from the way employer-provided private health insurance works. My point though is that the numbers suggest that there are larger structural factors that operate independently of that inefficiency.

It's possible that the pathologies of our system created those other structural flaws; like, if we had an NHS instead of private insurers, we wouldn't have built all these inefficient hospitals. But whatever the cause, we are where we are, and switching to single payer won't undo those problems.

Which sums up my concern about single-payer: it might be a good way to lock in a lot of structural problems for a long time. Meanwhile, if you just directly address the problems themselves --- stabilize the markets, enact strong price transparency rules, aggressively incentivize efficiency --- you might not need single-payer (an immense, disruptive change) in the first place.

Also, if we want cost outcomes approaching that of the NHS, we have to do more than simply enact single-payer. We also have to aggressively set rates, reduce compensation for doctors, fire a lot of nurses, and make people wait years for knee surgery.

You’ll note most of my commentary centers around employee provided health insurance. That’s because it’s the outlier. Other countries have similar systems to ours on the provider, Medicare & Medicaid side. Employee provided insurance is, as far as I know, unique. And it’s a dramatically stupid way to fund health care.

Further, it’s a less dramatic thing to change. We’ve already been through a much more impactful change in living memory in the form of moving away from pensions.

My position is that changing that are of funding brings price transparency to the biggest segment of the population & it derisks the migration.

It's not clear to me how it does that.

> Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with.

Medicare isn't a closed system, and isn't the majority of funding, so it has to deal with the structural results of the rest of the system, which is majority private pay (and heck, Medicare itself is a partially-subsidized private-insurance voucher system with a public option for it's core services, which exclude prescription drug coverage, which is provided through an optional partially-subsidized private voucher with no public option.)

Help me understand what exactly, in broad strokes, a single-payer system adopted in the US in 2019 would do to correct those structural problems?

(I asked roughly the same question upthread a few minutes earlier, so if you answer there, I'll see that answer and consider it an answer to this question too. Thanks!)

If Medicare overpays, then the entire system is really broken. The reason you see fewer and fewer private doctors hanging a shingle for a private practice is because you can't break even. Those that do, don't accept medicare, many don't even accept insurance anymore. They can't take medicare because they'd operate at a loss. They don't take insurance because they're a pain to work with and don't like to pay.

> But aren't those structural problems directly caused by the way we fund the system?

Yes. Almost entirely.

If that's true, and we stipulate that the two specific problems I called out are major contributes to the inefficiency of our system, you should easily be able to explain how switching to an alternate funding system would remediate them. Can you provide more detail?

This is a weird article that starts out with a customer service problem and ends up extrapolating an entire new health system out of it. The problem this person has is that they signed up for an HMO instead of a PPO, which is what most people in the US have. HMOs subject you to additional red tape in exchange for lower premiums; PPOs allow you to walk in to a specialist (though most Americans will see their GP first anyways).

Whether you get an HMO or a PPO, it is far easier to see a specialist in the US than it is in the UK. In fact, most health care economists would argue that it is in fact too easy to get specialist care in the US, and we as a result overconsume services without obtaining better outcomes.

"Rather like when the British rail system ground to a halt because of the wrong type of snow, the American health care system apparently is beset by the wrong type of patients: ill ones." That is so true. I'm not sure if the betterment of health insurance industry would be the solution, or the health insurance industry itself is actually the problem.

Thats a good quick chart I can use to pull up when arguing for a single payer system.

I think the biggest problem with single payer in the US is cultural, not even political - people simply don't trust the national government to do anything at an acceptable level (except when it comes to defense, the post office (74% approval rating), and the CDC).

How does this chart address the question of how we should fund our health care system? The problem is how much we're paying, not whether we pay for it in payroll taxes or out of pocket.

The chart shows a strong correlation between government funded healthcare, cost-efficiency, and effectiveness - that's how.

Correlation isn't causation. Switzerland's health spending is in line with that of Canada, France, and Germany, has roughly the same (better in some cases) life expectancy outcome, and is an entirely private system.

Life expectancy is also a poor way to compare health care systems, because major factors decreasing life expectancy have nothing to do with quality or access to care --- for instance, one of the most significant hits we take to life expectancy in the US is the prevalence of traffic fatalities.

You asked how the chart 'addresses' the question, not how it unambiguously proves single-payer will save US healthcare - if that's your standard, I'm afraid I, nor anyone else, can meet it.

And it has life expectancy, infant mortality, and preventable deaths - I guess they're all poor comparisons?

Finally, the Swiss system is private only by the standard that insurance companies are privately owned. If you look at how they must operate, and how patients pay for insurance, it's practically government run. From https://en.wikipedia.org/wiki/Healthcare_in_Switzerland : "private health insurance is compulsory", "covers a range of treatments detailed in the Swiss Federal Law on Health Insurance", "not allowed to make a profit off this basic insurance, but can on supplemental plans", "The insured person pays the insurance premium for the basic plan up to 8% of their personal income. If a premium is higher than this, the government gives the insured person a cash subsidy to pay for any additional premium".

The part of this comment that bears rebutting, I rebutted in your sibling comment. :)

In Switzerland, the basic insurance plan is defined by the government and everybody is required to participate in at least that plan. Everybody has the same deductible and out of pocket maximum and premiums (as paid by individuals) are capped at 8% of income.

If you don't sign up the penalties can actually be higher than premiums and if you persist in not getting insurance the government will sign you up and allow the insurance company to sue you for any unpaid premiums.

This system is nothing like what "private" means in the US. This would be called communism in our current political discourse.

How are you not describing the ACA system? The ACA makes health insurance compulsory (not as effectively as the Swiss system, to be sure), mandates a minimum health plan (quite effectively, and quite similarly to the LAMal), guarantees issuance, and prices through community rating, the same way the Swiss system does. US spending on health insurance is 6% of income, 8% if you include expenditures outside insurance.

I'm not arguing the US system is better or even close to as good as the Swiss system. We have a lot of problems, and overpay flagrantly. I'm saying the Swiss have a system that closely resembles ours (unsurprisingly, since ours is patterned on theirs) and theirs appears to work. That tells me our problems are orthogonal to the issue of private versus public insurance.

I think the weak penalties for not carrying insurance are a serious problem with our system, but you are going to have a difficult argument to make if you want to attribute the hundreds of billions of dollars we overspend in health care to just that factor, or even significantly to that factor.

I basically agree with you that we overfocus on the single-payer vs. private distinction. But I think there's more to it than that: when you get down to it, most Americans who want to reform the US health care system don't really care whether it's public or private. They care whether it's universal or not. The Swiss system is universal health care because the basic plan is capped at 8% of income at the federal level, with cash subsidies given to those with incomes lower than that.

By contrast, Medicaid in the United States is administered to the states, who have broad leeway in determining who is and who is not eligible for the system, especially after National Federation of Independent Business v. Sebelius. Income level alone does not necessarily qualify one for Medicaid. Medicaid is not considered universal health care, even with the ACA, and that makes a huge difference.

It's not so much that Americans don't want the Swiss system as that we're missing the crucial part of the Swiss system that makes people feel secure that they'll be insured.

Medicaid isn't the only option for premium-controlled health insurance in the US. As far as I'm aware, everyone in the US is able to purchase health insurance for at most 9.86% of their income in 2019, except:

- Those who earn less than 100% of the federal poverty level ($12k/year for an individual, $25k/year for a family of 4) in states that haven't expanded Medicaid (~2.2 million people [0])

- Those who earn more than 400% of the federal poverty level ($48k/year for an individual, $100k/year for a family of 4) but aren't offered health insurance through an employer (e.g., because they're self-employed or work for a small business) (~900 thousand people [1])

Both are legitimate and significant coverage gaps, but they only affect ~1.5% of non-elderly adults in the US. For comparison, the number of adults that qualify for free or subsidized coverage but chose not to enroll is about 4x larger as of 2016 [2].

[0] https://www.kff.org/medicaid/issue-brief/the-coverage-gap-un...

[1] https://www.commonwealthfund.org/publications/issue-briefs/2...

[2] https://www.kff.org/uninsured/issue-brief/estimates-of-eligi...

Sure, it's similar (no coincidence, as you point out). Most people in the US don't directly participate in the ACA marketplace. For all the talk about freedom of choice, i'd venture that the majority of Americans have no real choice in what insurance they'll get (apart from their freedom to switch jobs or pay a higher price on the exchange by forfeiting their employer's contribution).

We also have a significant population (~15%) on a public system that has an influence on prices that everyone pays but no authority to negotiate drug prices.

I don't think that any one of these differences is an explanation for the gap between ~11% of GDP and ~17% but there are enough of them that it's hard for me to decide public vs private is orthogonal.

I think universal single payer healthcare would be wonderful, but the issue of healthcare is politicized enough as it is. With a private company I can fight. I might lose, I might have to go elsewhere, but I have a choice. With the government I have no choice, and I have no recourse. When has that ever led to better outcomes?

For England: You can usually chose your doctors in the NHS. Here's the patient facing info: https://www.nhs.uk/using-the-nhs/nhs-services/hospitals/nhs-...

Here's the bureaucratic document for commissioners of general practice (primary care doctors) (sorry you need to ctrlF for "choice".) This document also tells you where in law patient choice is detailed: https://www.england.nhs.uk/publication/primary-medical-care-...

> and I have no recourse.

If the treatment is negligent and causes harm you can sue. There are cultural and legal differences, but suing the NHS is possible.

You can still pay for private healthcare if you want to skip waiting lists.

In terms of choice, the NHS allows you to shop around for your specialist, and they're also the same doctors you'll see privately.

It is stupid to blame Obama or Trump even for the current state of Obamacare.

The parties involved right now are resulting in a much worse than medicare solution as it is similar to the three wolves one sheep version of democracy (which is the whole premise of libertarian concerns about democratic socialism). It is an attempt to obfuscate the otherwise obvious corruption and theft that is healthcare. Here the wolves are the AMA(doctors), insurers, pharma, and the politicians claiming to want to solve healthcare. The AMA and insurers have insane billing policies based on assuming inept doctors and corrupt patients.

Most insurance today is just passing on the discounted (actual) price on to the insured co-pay or deductible. They cover very little normal costs of medicine nor do they provide any actual services for their premium.

The main reason we don't have universal medicaid/medicare is similar to why the IRS doesn't do electronic filing themselves. Billions of dollars of middleman and tens of thousands of otherwise worthless jobs are on the line.

We need a private/public system. It will initially look costly and it will suck (differently) for doctors and hospitals. However, in five to ten years the costs will stabilize and insurance and other services will be more honest as they will have real competition.

Also, he should try to just fly back to the UK for non-emergency issues. Most foreign friends I have just keep insurance in their home countries as it costs usually 100-200 a year. A $1k flight back to see your family is cheaper than any surgery in the US.

The HMO system is misery. PPOs are better but costly :/

Are you in an area where Kaiser Permenente operates? It has been, on the whole, a great healthcare provider. The level of integration of their centers is great--I can walk downstairs for an MRI or Xray or lab test (no waiting for one doctor's office to phone in authorization/orders). Electronic records are fully and usefully integrated. Costs are relatively low, and there are several options of locations in my area--small, neighborhood office; a larger, integrated facility; and a 24-hour hostpital-like facility. They also have partnerships with other hospitals in my area, so I can go to other hospitals and be treated fully under KP insurance. There are so many advantages, I've kept my KP plan over several employers (including a stint on the Healthcare marketplace).

I'm using the KP health system. Its pretty awesome. Everything in integrated. I can use the website or phone app to check any of my test results. I can message my doctor for a e-consult at no extra cost. They usually reply within half day. I can book most appointments online. If I went to a specialist, I can continue messaging them in the future. And since the doctor is gate keeper, you just need them to approve a procedure and it will happen.

I had Kaiser years ago and while the quality of care was high I remember eight- to ten-week waits to see certain specialists for non-critical issues.

The HMO approach concerns me more as someone with special medical needs -- I would strongly prefer the flexibility to see a specialist that is experienced with my specific condition as I've had problems with doctors whose only experience with my condition is in a textbook

HMOs are great if you're healthy and plan to remain that way for a while. I have the same deductible and co-pays as a PPO but pay about $200 less per month. The level of care is adequate for my needs, and I actually go to the doctor now because the HMO is integrated with the provider network, so I can book appointments online. Since the HMO also owns the lab and other facilities at the clinic everything that they do to me is covered. They even have an optometrist in case I need an eye exam. Their pharmacy is also really quick compared to most places.

HMOs fail most often on mental health from anecdotes of friends on them. They force you through only one provider who may be qualified or not, and you get a "permanent record" which can actually really hurt your care in the future. If Jill the ARNP says you were awful and maybe faking a sympton, and she has lunch with a bunch of other doctors in the cafeteria, you're gonna get treated like crap.

Yeah, I can see how that would be an issue. The HMO I'm on actually specifically covers private practitioners because their in-house practitioners are totally full for months. And it was pretty damn easy to get an appointment. I just had to call in and get a preapproval.

People don't plan to remain healthy?

Based on most people's actions, it would appear not.

Excessive eating, drinking, smoking, and insufficient exercise and sleep seem to apply to most people.

I'm in kidney failures (due to an auto-immune disease.) I have to do dialysis every day. I'm super careful with diet and lifestyle. But many people are not. My dietitian tells me stories of dialysis patients that go out for massive fast food meals before coming in for dialysis. Dialysis functions maybe at 10-20% of a normal kidney. Its meant to keep you alive not pull out wastes products from your excesses. It doesn't do a perfect job. These people are slowly just killing themselves.

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