Promoters of the Affordable Care Act avoid using the word “rationing.” But, as Roxeanne de Luca reminds us, that’s exactly what’s going to happen:

We’ll eventually all have “free” doctor’s visits but be denied life-saving treatment, which is the exact opposite result that you want for insurance, which is supposed to cover the really expensive things you can’t pay for yourself. It would be like homeowner’s insurance that covers a leaky faucet for free but doesn’t give you a cent if your house burns down.

Although I must note that my own homeowner’s insurance has doubled in price in three years, and I haven’t figured out a way to blame that on Congress. Yet. (Yes, there was that nearly-five-digit claim, but as one might expect from a shared-risk scenario, people who didn’t have those claims got their premiums hiked as well.) Doesn’t cover leaky faucets, unless they do something like leak into the wall. I’ve replaced one in eight and a half years; it wasn’t doing anything other than wasting water.

Things like this:

Picked up a plastic doo-dad from the pharmacy yesterday. It’s just a plastic tube that goes with an inhaler, makes it easier to get a full dose of medicine or something. Whatever. It’s just a piece of plastic, no drugs of any kind. Still, the pharmacy would not sell it to me without a prescription, probably because it’s a “medical device”, and insurance won’t pay for it unless a doctor specifically orders it, and because of all this administrative overhead what should cost a dollar ends up costing the insurance company a zillion bucks.

Which gives me an excuse to quote Dr G. Keith Smith of Surgery Center of Oklahoma:

Prior to Medicare, the cost of hospital care was affordable for all but the extremely poor. The hospital bill for my birth in 1961 was less than $100, a small amount even taking inflation into account. Retired orthopedic surgeons have told me that repair of hip fractures in the pre-Medicare days ran about $300.

What happened? Medicare happened. Physicians wanted nothing to do with this scheme in the early days of the program, so to sweeten the pot, the federal government offered to pay whatever the physicians wanted to charge.

Guess what happened to physician fees?

Yours truly pointed out in 2005:

In 1998, laser eye surgery cost more than $2200 per eye; today it’s about half that, though it’s not covered by insurance plans or by Medicare. Or maybe because it’s not covered by insurance plans or by Medicare, which have their own ideas about what medical procedures should cost.

Dr Smith, along these same lines:

If you walk in to an ophthalmologist’s office and ask them how much they will charge for your Lasik surgery, you will get an answer. An amount. No “ifs, ands or buts.” Try this at your local hospital. Ask them how much for your hernia surgery or your gallbladder removal. Good luck. You probably won’t get an answer, and if you do, the amount will shock you.

Then again, nothing about health-care costs shocks me anymore, except for the claims by various governmental types that they’re going to “control” those costs. Sure they are.

The Pre-Death Panel at CFI Care [not its real initials] has been known to express, sometimes quite loudly, its preference for cheaper drugs over more expensive ones — whether or not the cheaper one actually works. I do yell back at them, though:

I paid your absurd five-times-the-price-of-generic copay because this stuff works and there are no generics. Simple as that. Ninety days from now, I’ll be happily paying six times the price, just so I don’t get any more phone calls from you addlepated schmucks.

I am, of course, not the only person who has to deal with this sort of thing:

“We’re declining to pay for that specific prescription because we do not feel it is effective for treatment.”

“The same medication that I have been taking to help control my seizures for the last ten years? That exact same medication? The one you have decided with my excellent medical care in mind is not effective for treatment of my medical condition?”

And since this ought to be repeated:

I do not believe that allowing a computer generated data program to decide that one drug is more effective for treatment than another drug just because it costs twenty five cents less per pill is the best possible treatment for anyone.

We can expect more of this as the government adds its own cost-savings schemes into the mix. In the meantime, she’s paying the inflated price routinely charged to the uninsured. I am minded of P. J. O’Rourke’s dictum: “If you think health care is expensive now, wait until you see what it costs when it’s free.”

Disclosure: The stuff I was on eventually went off patent, so I can actually get a generic, about which they don’t fuss in the least. Imagine that.

Bill Quick, in a post from the summertime that bounced back into view, points out the basic structural problem with the current paradigm for so-called “employee benefits”:

Those “free” benefits are paid for by you with your much reduced salary. Is your employer one of those who notes on your paycheck all the “free” benefits they are so graciously bestowing on you? Well, add all that money directly to your own salary, and that’s how much you’d be earning without those “freebies.” Think you could shop around and do better than what your employer, GargantoCorp, is spending your money on for “your” benefits?

Assuming, of course, that GargantoCorp would actually raise salaries to compensate for freebies withdrawn, which in the current corporate climate seems unlikely.

That said, though, were the government’s thumb removed from the scales, I suspect I could find quite a nice package for way less than is being spent now on my ostensible behalf. Then again, when have you ever seen a spoiled child give up a toy willingly?

By now most people have had the disconcerting experience of having some medical procedure or other deemed Not Covered because the physician didn’t enter a code that passed muster with the insurance company. Dr. B used to say that “I could either know billing or know medicine.” But now there’s a whole new set of codes:

Physicians have gotten a few laughs from the new and voluminous set of diagnostic codes known as ICD-10, which distinguishes between being struck by a duck (W6162XA) and being bitten by a duck (W6161XA).

[Insert "quack" joke here.]

The new codes were required as part of HIPAA. As it happens, ICD-10 is five times the size of the old ICD-9, and it’s not so hard to see why:

ICD-9, for example, recognizes that patients may seek treatment because they were bitten, and gives clinicians a few choices, such as dog, rat, snake, arthropod, unspecified animal, or human.

ICD-10, in contrast, is a veritable zoo of bite codes — horse, cow, cat, pig, shark, dolphin, sea lion, alligator, macaw, parrot, and duck, to name just a few new kinds of jaws. And for each kind of bite, physicians can pick a code for an initial encounter, subsequent encounter, or sequela.

And from the Just Try to Top This file:

Some accident codes, however, defy the imagination, such as the famous V9107XA: burn due to water-skis on fire, initial encounter.

But there’s still no code for being turned into a newt, or for recovery therefrom.

Yes, it’s been a long, long stay inside this Bessemer-converter simulation they’ve been calling a “heat dome,” and just when I was adding a couple more points to my Despair Quotient, I got a little surprise from the American Association for Nude Recreation: one of those prescription-savings cards that is definitely Not Insurance, nosiree.

Now this is a fairly common “membership benefit” offered by lots of organizations, and it’s not like I’ve never seen one before. Still: in the age of the four-dollar generic, are these things even useful anymore?

It is an article of faith among everyone to the right of Barack Obama, which isn’t technically “everyone” but is probably close enough for government work, that government-provided health care would suck rocks, and sedimentary rocks at that. (None of that cool — formerly hot — igneous stuff.) On the other hand, I would be remiss in my duties as a kvetch if I failed to point out instances where the private sector has prompted a response of “You’re not my mother.”

Here’s one now, in fact:

I got a “card” yesterday from my health insurance.

Um, yeah. Nothing says, “OH HAI, you are one year closer to decrepitude” than a card (a flyer, really) from your health insurer. In English AND Spanish.

I wasn’t really very happy with what it said. But then again: I suppose this is what you get if you are a conscientious/concerned person in a world where too many people are not.

It was a list of “healthy habits.” And a strong suggestion that I follow those. (The unwritten, but assumed-by-me, subtext: because then you will cost us less money).

I hate to be Debbie Downer’s brother Dave, but it gets worse. CFI Care (not its real initials) sent me a letter the other day noting that I’d had one particular prescription filled eleven times last year — not twelve, but eleven — and therefore they had reason to question how seriously I was taking my condition, or some such foolishness.

On the other hand, if you accuse me of being conscientious and/or concerned, I will go out of my way to sneeze on you.

TrueHoop’s Henry Abbott opens his mail and finds this:

It’s often pointed out that the Miami Heat regularly measure body fat percentage on their players and that it’s required they be below a certain threshold in order to play. Antoine Walker was famously withheld from games for not meeting this requirement, for instance… While athletics are often a whole different breed than most other jobs, this seems to tread into discriminatory territory that would never be allowed in any other workplace.

For “would never,” read “will, starting almost immediately,” no thanks to the lackeys of the Nanny State.

Then again, I am notoriously lackey-intolerant. And Abbott, to his credit, objects:

Generally, the proper response is to say “butt out.” If I can do my job day in and day out, the other stuff about me is my business. And in the NBA, Charles Barkley and Shaquille O’Neal, among others, would seem to prove that players can perform at elite levels without being the leanest people in the room.

And high salaries are not a good enough excuse to demand players be held to a different standard.

I was thinking of a different combination of seven letters — albeit still configured as four/three — but the message is much the same.

Health care costs to stabilize or even decline? Pie in the sky, says Jenn:

[W]e have a better chance of Osama bin Laden converting to Catholicism and becoming the next Pope than this current health care reform act does of actually containing costs.

There are such things as miracles — though that’s seldom the way to bet.

Being the highly-efficient procrastinator that I am, I managed to delay the annual eye exam, which was due around Labor Day, until yesterday. (Of course, if I were a perfect procrastinator, it would still be on the back burner more or less indefinitely.) I arrived about fourteen minutes early, and was immediately paid back for being dilatory: some time between the time I was supposed to show up and the time I actually did show up, they’d relocated the practice.

Okay, fine, another two miles and change. I can do that in … well, twelve minutes, counting the return to the car. Rush hour’s over, isn’t it? (“At 8:18 in the morning? You should live so long.”—ed.)

My formerly spotless bill of health was slightly less so this time around: still no macular degeneration, and apparently I have optic nerves of steel, but there’s the faintest hint of cataractivity on the fringes. On a scale of zero to “hire a seeing-eye bat,” this ranks about 0.5, said the doctor, and I might have to worry about this in, oh, fifteen or twenty years.

(Aside: I threw this up as a question on Facebook: “Is it somehow counterproductive to utilize the services of an extremely pretty optometrist?” Because of the distraction, you know.)

Extra bonus: an object lesson in Why Health Insurance Is Hosed. First, some background, from a presumed industry insider:

It is best to always charge for a refraction (assuming the test was done, of course) and show it as a separate line item fee on the patient’s ledger and receipt. I would do this in all cases: private pay, vision plan coverage or medical insurance coverage. The refraction fee can then be billed to a third party or may be collected from the patient, depending on the coverage, but I believe the fee should always be entered. It is simply good policy.

Medicare, as it happens, won’t pay for refractions. (This is the procedure that involves squinting at illegible bug marks on the wall while lenses are whirled in front of your nose.) Neither will most standard insurance plans, though vision-care plans apparently will. I don’t have a dedicated vision plan, and the practice was following the above advice on breaking it out separately.

Now here’s the fun. The part of the exam that didn’t involve refraction, which took approximately half of the exam time, was listed as $125, and CFI Care (not its real initials) will be billed for $68.49 after a $30 copay. I conclude that this is supposed to be worth, well, $98.49.

The refraction fee, noted as a separate item on both the invoice and a wall plaque, was — wait for it — twenty bucks.

Now you could argue that the refraction can be, and in this case was, done by an assistant. (To the dilate delight of these old eyes, the assistant was just as gorgeous as the doctor.) But the doctor has to review the results anyway, so that won’t wash as an excuse. Which leads me to believe that insurance coverage, aided and abetted by government, has so screwed up medical pricing that the best way to save money, when circumstances permit, is to opt for something that isn’t actually covered. Obviously circumstances won’t always permit, but I have to figure that the $50 I actually paid was pretty close to what all this would sell for in a freer market than this. In the meantime, some poor sod with no insurance at all is going to get a bill for $145, because that’s the way the system works.

And come to think of it, $50 for an hour’s work is about half what I pay to get my car worked on. On the other hand, it’s easier to get parts for the car.

Now that insurance is supposed to cover mental-health disorders to essentially the same extent as it does other ailments, Megan McArdle has some doubts about the whole thing:

I am very sympathetic to the plight of the mentally ill. Unfortunately, most of the people who will tap the benefits are not severely ill people who need intensive care; they’re people who are unhappy. Unhappiness is not a condition for which psychotherapy, or antidepressants, have been shown to be very effective. (Severe clinical depression, yes. But contrary to the belief of people who felt awfully down the time their boyfriend left them, these two conditions are not the same thing.) Since the moderately unhappy and dissatisfied are much more prevalent than those with serious disorders, that’s most of what we’ll be paying for: someone to listen to complaints. That’s what Senators are supposed to be for.

On a more serious note, I feel like we could have achieved the laudable goal of ensuring that serious mental illnesses are not left untreated (at least, in cases where the patient wants to get treatment), without guaranteeing cheaper psychotherapy for America’s ennui-laden affluent classes. Of course, then we’d have to recognize the fact that this stuff has to be paid for, rather than pretending that benefits can somehow be magically generated for free with just a wave of the regulatory pen.

Laden with ennui as I am, I’m not anywhere near affluent, and I struggle with something that is more than mere unhappiness but perhaps less than clinical depression. (I know from clinical depression: I had it through most of the 1980s. It broke up two households, including one with only one person living in it, and landed me in the Home for the Bewildered for a month and a half.)

Treatment for this particular inchoate ailment consists of one tranq and ¾ to one full sleeping tablet, daily. Estimated costs before insurance: $1,000 a year. This will buy — what, five, maybe six sessions on the couch with Dr Sturmunddrang?

And besides, since when do Senators listen to complaints?

Yes, two of them. Color me indecisive. (Or maybe you shouldn’t.)

I lean toward the “Never speak ill of the dead” side of the spectrum, myself, so it would not have occurred to me to say what Jenn says here about the late Howard Zinn:

I’m not sure he will join Teddy Kennedy in hell but if he doesn’t he should be made to spend eternity in a Catholic school purgatory with nuns slapping history into his head with yardsticks. I hate to think how much damage that book of his has done to America.

Okay, it would not have occurred to me to say it out loud.

Sonic Charmer on health care viewed as a utility:

Notice that most people aren’t really all that happy about how cell phone plans work — signing lengthy contracts, paying high monthly fees whether or not they use it, etc. I submit that the way we pay for health care has a lot of the same problems (and more — after all, at least the government doesn’t incentivize our employers to garnish our paychecks to pay for our cell phone plans) — but people just don’t notice it because they don’t think about health care the same way that they think about their cell phone plans.

They should. And if Basic Health Care was essentially a utility, a monthly service, like cell phone plans, then maybe they would — and maybe they’d stop and see that what they’re asking for when they clamor for government to “reform” “healthcare” is the health-care equivalent of asking the government to take over Sprint and then force everyone to sign up for 50-year cell phone contracts in which the government has the power to limit the number of minutes.

[Insert reference to iPhone — not available on Sprint — here]

As we had been warned, the insurance carrier for 42nd and Treadmill’s CFI Care (not its real initials) will be changing on the first of January, and we sat through the usual enrollment meeting yesterday.

I am pleased to report, however, that a trace of transparency is creeping into the proceedings: alongside the usual handouts was a list detailing the actual price as charged last year, the price that would have to be paid for renewal (which was a third higher), and the price quoted us for the new package. I hadn’t had access to these figures, but my ballpark estimates were well within the foul lines. And to my knowledge, they’d never divulged this sort of thing before.

Full family coverage, if you’re curious, would have gone up to $14,172 a year. There are two options for the new year: same coverages, one has a larger network. The more expensive of the two will run $12,141. (There are add-on packages for vision and dental, which didn’t go up very much by comparison.) As a single person, I get charged $3761; the dental runs an additional $273. (Had they renewed with the previous carrier, I’d be looking at just over $6000.) Last year’s claims, mostly for drugs plus one CT scan, were in the $1800 range.

I say “I get charged” because that’s the actual cost of the policy. I pay nothing toward it in the way of premia, having served X number of years; 42nd and Treadmill picks up the tab. The coverages will be changing only slightly with the new carrier: office visits will be standardized at $30 instead of a lower tier for the family M.D. (or D.O., in my case) and a higher one for specialists. Prescriptions, I suspect, will be just about a wash, assuming I can somehow sidestep the stultified “step therapy” business on my antihypertensives.

You don’t see the government offering to/threatening to [choose one] take over the auto-insurance business, which prompts David Fleck to speculate: “What if health insurance were really like auto insurance?”

First off, I think we’d have to assume that it would be mandatory, the way that car insurance is; everybody would have to have some kind of basic coverage. There would be competing companies of varying sizes and quality competing for our health insurance business. Presumably, the mandatory minimum coverage would be relatively inexpensive, and not cover a whole lot.

A lot of things wouldn’t ever be covered; routine exams, prescription drugs, etc. You’d be on your own for that stuff.

You could buy more expensive plans to cover more and more dire illnesses and mishaps. However, the more often you made claims, the greater the probability that your premiums would go up, and eventually your insurance company could boot you out; if you couldn’t find insurance anywhere else, I suppose then (idle speculation here: no correspondence with real world) you’d have to go onto some sort of government run last-ditch program for the incorrigibly unhealthy.

We are assured that the cost of treating the uninsured increases the premiums for those who are insured, though the quantity of said increase is not known for certain. However, I do know how much uninsured motorists cost me: $337 a year, the single largest component of my auto-insurance premium. (Yes, even more than collision, and I drive an overpriced sedan with a lowish $500 deductible.)

And eventually, we’ll all be totaled out:

I’m sorry, Mr. Fleck, but we’ve run the numbers on this last set of medical bills you’ve submitted for processing, and we have determined that the total cost of this health care exceeds your blue book value, which for someone of your age, sex, condition, and socioeconomic status, is approximately 1600 dollars, plus about 85 dollars salvage value for your raw materials. The check will be in the mail shortly. We’ve appreciated having you as a customer, and have a nice day!

[Insert "Progressive" "joke" here]

You may remember this kvetch from earlier this month:

[W]hile combing through the insurance materials online — I still haven’t received anything resembling a card from the bastards — I discovered that they will not cover my antihypertensives unless I throw away 120 days of my life experimenting with stuff that may or may not work, but which will cost less.

I now have a card. In fact, I now have two cards, having requested one from their Web site during the period when I had none.

More interesting, though, is the material received yesterday on New Pharmacy Benefits. It’s still three-tier (formulary is open), precertification and quantity limits still apply as before — but there’s no mention of step therapy, the very practice about which I grumbled.

Now the punchline: After consulting with my doctor and determining that the action would likely be similar, last week I ordered 90 days’ worth of the Tier Two drug they would have preferred to the Tier Three drug I’d been using. Assuming I survive, and for the moment I’m assuming exactly that, I’ll be up $75.

Further punchline: Their benefits report online suggests that they’re out slightly more for this stuff than they would have been for the ostensibly-pricier drug.

This could turn out to be a whole lot of fun after all, given my propensity for rattling cages.

What worries me is that somebody might think this is a really swell idea:

Ordinary Americans will be able to afford medical costs by getting coverage through their car-insurance companies. Conversely, to end carbon emissions (by making driving too expensive for ordinary Americans to afford), let the HMOs handle auto insurance, too.

The great thing about car insurance companies is that you only deal with them for big-ticket items and handle everyday maintenance yourself. This makes automotive care affordable for almost everybody, which leads to more driving and more pollution.

Unless the HMOs handle it. Need an oil change? Then call your primary car mechanic and make an appointment through his secretary to determine that your car does, indeed, need an oil change, and you’ll be allowed to schedule a visit to an oil-care specialist three weeks from next Tuesday (don’t forget to ask your boss for time off work), and your mechanic bills the HMO some huge amount but your co-pay is only $25, plus another $20 for your primary car mechanic visit.

This is not too different from getting a service appointment at the local Infiniti store, though an oil change will run me a bit less than $45 and they’ll actually lend me a car for the duration. What’s more, they’ll wash my car.

But then it starts to get tricky:

What happens when your tires start going bald? Once your PMC confirms this diagnosis in writing, the insurance company will pay for a new set at the tire shop five towns over from where you live (i.e., the nearest one belonging to your HMO’s automotive provider network. The other 19 tire shops in your area are off-limits to you).

Of course, if you want to buy a new car, you’ll need your PMC to check it over and look for pre-existing conditions. If the car’s in less-than-perfect shape, you might not qualify for coverage at all. Sucks to be you.

And let’s not forget gasoline! It’s extremely dangerous when used improperly, so instead of allowing folks to buy it willy-nilly, it’ll be prescribed on a need-only basis. Since you’re not legally responsible enough to determine that need on your own, your primary car mechanic will authorize how much gas you need, which station you can buy it from, the proper octane rating and whether you really need gas at all.

Remind me to block Henry Waxman’s IP address, lest he see this.

State Insurance Commissioner Kim Holland notes that rather a lot of Oklahomans don’t have health insurance, and it may be necessary to force the issue:

Barring a law requiring the purchase of health insurance, which Holland concedes would be a political long shot, “inducements” that penalize those who fail to insure themselves would help, she said.

Among the possible inducements Holland proposed was forfeiture of football season tickets to University of Oklahoma or Oklahoma State University games, forfeiture of lottery or gaming winnings, loss of state income tax deductions or licenses to drive, hunt or fish.

“None of those are very pleasant, but there needs to be a consequence,” Holland said.

Depending on whose numbers you want to believe, somewhere between a sixth and a third of Oklahomans have no health coverage, and there’s this little cultural factor getting in the way:

“We have developed this culture over the years that some don’t feel like they have to pay their medical bills,” [Holland] said.

Imagine that.