> She lost her health insurance because she exceeded the policy limits and had to skip her last chemo treatment.
What in fucking hell is this? An insurance exists to protect people from going bankrupt due to health issues, not to screw people over when they're already in no position to fight.
It is legal because there was a limit defined in the policy.
No insurance is open-ended, sky-is-the-limit. In many cases (e.g. auto, home, business) the limit is capped at the value of the assets that are insured. In other cases (liability) there is a defined dollar limit. My homeowners and auto policies have liability insurance but there is a limit. If I caused a traffic accident with signifcant property damage and multiple serious injuries, my liability insurance limit would likely be exceeded.
Health insurance has limits as well, even with the recent changes that the ACA introduced. The ACA removes limits on "essential health benefits" but who decides what those are? Hint: Not you.
If there were no limits on health insurance there would be little backpressure to ensure that care provided is worth paying for, or to put it another way, has real benefit. You'd have hopeless cases on life support forever, or unrealistically expensive treatment of conditions for which there is no real hope.
Sad as it is, some health problems can't be fixed, and at some point you need to admit that and stop throwing money away. One more chemo treatment would very likely have made little difference in the outcome for this woman.
> One more chemo treatment would very likely have made little difference in the outcome for this woman.
Internet forum punditry in a nutshell. This is a ridiculous thing to assert with the amount of information available.
Due to the dangers of chemotherapy, the number of treatments is already carefully balanced against the response to the treatments and our best statistical models. The last treatment can certainly be the difference between remission and recurrence; that's why we give it.
"If there were no limits on health insurance there would be little backpressure to ..."
Also, it wouldn't be insurance.
People think that insurance is "something that I want that does nice things for me". It's not.
Insurance is a math problem and it has a precise answer. If you go beyond that answer it doesn't work. Either you're getting screwed or the (hapless) insurance company goes out of business.
The math problem is tricky in a lot of ways though. For example, the rate the insurance company pays doctors is different than the retail rate. Lots of people don't realize this. It also brings up two pretty interesting questions. One, could the patient have covered the last session at the price insurance companies pay? And two, does the insurance company run down that upper limit based on the amount they're billed, or the amount they pay?
There's another interesting policy question. Insurance, flat out, can't pay for everything. So, given that they have a pool of money, do you allocate that toward the least sick people? That's probably a better approach to more total years of survival. ensure the healthiest 50% (or whatever) get excellent care, and let the rest go. Alternatively, do you triage and spend the the money on people who have a slim chance of survival, making the heroic rescue day after day?
I find that policy decision horrifying. I honestly have no idea how they pick. But it's pretty obvious, somebody getting chemo means 100 other people aren't getting, for example, cholesterol medication.
I'll agree it's just an equation. but man, i'd love to see those tables showing years of human life saved based on condition and treatment. Just to add a touch more cynicism, should those years be weighted based on economic productivity? Would we be better off with 10 more years of Steve Jobs or 10 more years of Grandma? My gut says Grandma, but... it's just an equation.
huh. that's weird. it seems like all the customers throw in their money every month. some percentage of that must go to overhead and profits, the rest would go into a pool for medical care. Each month the insurance company would pay whatever is required for specific obligations, with any extra carried over to the next month. From time to time there would be random fluctuations, unusually high numbers of heart attacks for example, and they'd run at a loss. I thought insurance companies work just like casinos with harder to estimate probabilities of having to pay out. The thing that's really cool about being an insurance company, you don't have perfectly clear obligations. With a casino, they land on double zero at roulette, the casino has to pay. With insurance, the insurance company gets to decide the worthiness of paying out. Oh yes, this person has cancer, but the chance of survival is quite low, so we're not paying for chemo.
But, clearly, i'm mistaken. Could you elaborate on how the insurance business really works?
> could the patient have covered the last session at the price insurance companies pay?
No, cash payers pay less, not more.[1] But even "less" is financially devastating for most people in the context of chemotherapy.
> does the insurance company run down that upper limit
based on the amount they're billed, or the amount they pay?
The amount they pay; the former would be fraud.
> given that they have a pool of money, do you allocate that toward the least sick people?
> you don't have perfectly clear obligations
> the insurance company gets to decide the worthiness of paying out
Insurance companies do not operate for charity; if they have extra money, it goes to shareholders. Outside of a few publicity stunts, companies have clear obligations as specified by copay, deductible, maximum limits, and covered providers/procedures, and people who pay more for better coverage get better coverage (so poor people have a bad time). But insurance generally doesn't have robust margins--many earn their profits purely on float.[2]
You are of course right that questions of allocation always involves questions of values. But these questions are decided by the political process, in battles over healthcare regulation in areas such as minimum coverage requirements, excessive rates, and preexisting conditions.
Cash payers may pay less, if they have the opportunity and sense to negotiate the prompt-pay discount. I was a freelancer before ACA and paid more than i should have out of pocket, because i was dumb. But yes, if you're savvy, you have a chance.
Getting medical care out of insurance's prying eyes may have some weird consequences, payer-provider agreements might prohibit direct interaction [1]. Seems unlikely they'd drop you, but weird things might happen if it turns out you get a CT scan from X that doesn't know you have insurance from Y, and X has another agreement not to take cash payments from Y's customers.
I'm not saying you're wrong, i'm saying just like everything else in health care it's really fucking complicated.
> The amount they pay; the former would be fraud.
The ACA specifically calls out 'dollar value'. AFAICT, it varies from state to state. If you hit me with your car, and the court decides you have to pay my medical bills, North Carolina limits it to just the actual amount paid. Wisconsin says it's up to the court to decide what 'dollar value' means, and they can take into account billed and paid (and anything else they want). That's all personal injury stuff though, there might be special definitions for ACA.
> Insurance companies do not operate for charity;
Yeah. I'm not claiming they should. I'm not a fan of the system, but it's the system we have. As with all things, the way I think it should work, and the way it actually works are very different things. Mostly, i was trying to call out how ridiculously complicated it is. The OP's assertion:
> Insurance is a math problem and it has a precise answer.
may be true. But that math problem is way beyond the 3 body problem. I don't think we can really find a precise answer for any real world case.
> With insurance, the insurance company gets to decide the worthiness of paying out. Oh yes, this person has cancer, but the chance of survival is quite low, so we're not paying for chemo.
I don't know about US, but it seems like normal people would have laws and regulations to govern that kind of decisions.
In theory, you do. Lots of companies sell insurance and you can buy the coverage you want. In a single payer system, you are stuck with what the government gives you and that is where the "death panel" talk comes from.
> it seems like normal people would have laws and regulations to govern that kind of decisions.
Of course there are laws and regulations. In practice, a patient that will cost millions of dollars probably won't live that long. So it's advantageous to simply delay a decision. Deny coverage, get sued, go to court. If the process takes 6 months the patient will just die and the problem goes away. How do you prove someone is acting in bad faith? Short of an email that says, "Let's fuck this guy over and save 5 million dollars" it's not going to happen.
I'm sure the vast majority of people in insurance are honest, hard working, ethical, respectable people. But the system is inherently corrosive to those qualities. Saying "no" to a marginal case can save the company millions. Health insurance in critical cases is pretty much the definition of perverse incentives.
edit
so, appending crazy rant. sorry.
Healthcare in the US is insane. Something like 60% of people are already covered by a single payer system with medicare, medicaide and the VA systems. it's pretty much just 20ish year olds to 65 year olds who aren't poor and weren't in the military that are out on their own. I find it baffling that medicare, which takes care of retirees, wasn't just extended to cover everyone. Old people get sick. we already handle the really expensive part of health care via socialized medicine. Are there horror stories? yes, absolutely, but 200 million people are handled by those systems. For what they are, they work pretty well.
There are literally books with lists of all the things we know that can go wrong with people, and protocols for how to resolve those problems. I really wish there was a minimum floor for people. You break your arm, we follow protocol A. It's a compound fracture? Protocol B. Paid for by everyone's taxes (bigger pool of money is more resistant to random fluctuations) perhaps we can't afford to treat non-life threatening conditions quickly. That is indeed a risk, and the major complaint about socialized medicine.
However, that can be mitigated by supplemental insurance or out of pocket payments. Not many 40 year olds get cancer. it seems like we can spring for some basic coverage. If wealthy people want more, they can pay the difference one way or the other.
The current state of affairs is shameful. People who ought to be at their peak of earning potential are most at risk for being destroyed by illness. We, collectively have invested vast resources so those people at their peak can earn a living, raise a family, and generally make the world a better place by their labor. It's a rare event to be knocked out by illness, we ought to get those people back to health as quickly as possible. But, we don't. But hey, on the upside, CI is at 137 a share. so that's good, i guess.
In that case, health insurance is largely bunk. Major medical insurance is insurance. The rest of it, regular doctor visits, copays, eye exams, dental exams, is a payment plan.
Minimum Essential Coverage eliminates major medical only plans for people over a certain age, somewhere around 25 or 30 years old. So I end up paying what I think is an obscene $260 a month for the cheapest plan in my state, a Bronze plan with a $5000 deductible and only pays out 60%. My insurance is triple what it was with a major medical plan that paid out 80%. I do not consider this an improvement. Going back to bartering chickens and services would be an improvement. Destroying the perversion that is health care as a financial product to single payer would be an improvement.
Yeah, but they might live for another 6 months, or 18 months. They might see there kid graduate or get married or met a grandson in that time.
Also, a close family friend was given 6 months to 3 years to live when her cancer spread through her body. It's been 10 years. She is getting sicker and sicker and on chemo the whole time, but she is still managing to attend the odd family function when she is feeling up to it.
This shit isn't a game, these are peoples lives and we need to make sure they can live it even if it means a few less unicorn start ups.
> No insurance is open-ended, sky-is-the-limit. In many cases (e.g. auto, home, business) the limit is capped at the value of the assets that are insured. In other cases (liability) there is a defined dollar limit.
Note that no insurance's unwillingness to pay results in the death of a person. This seems like a very US centric way to think.
>If there were no limits on health insurance there would be little backpressure to ensure that care provided is worth paying for, or to put it another way, has real benefit.
And yet the US has a severe problem with over-diagnosis and over-treatment of a wide range of stuff, causing a lot of harm to many people. This overtreatment has driven up costs; it's one of the reasons medical costs in the US are so high.
> If there were no limits on health insurance there would be little backpressure to ensure that care provided is worth paying for, or to put it another way, has real benefit.
Insurance companies deny coverage for things all the time, for example there is currently a drug cocktail that costs 84k usd with a very high success rate in curing hepatitis c[1]. If you happened to be diagnosed with it tomorrow you would not get this drug, you would have to try the much less expensive (and much less effective) alternatives because your insurance would simply decline to cover the effective drug. I don't see how the lack of a maximum coverage limit would change that.
I think there's explanatory power in remembering that private, for-profit insurance companies have as their corporate priority maximization of shareholder value. Protecting people from bankruptcy due to medical expenses is not a corporate goal.
If word gets out that a company's insurance is kinda shitty, they're going to find themselves with fewer customers going forward, which is not good for shareholder value. Nickle and diming on a claim isn't where shareholder value comes from, but rather providing a good product that does what it is meant to do.
> corporate priority maximization of shareholder value.
I'm not sure if you're commenting on their observed behavior or their actual obligation. It would be good to put the phrase away since it's usually short-hand for a moral judgement on short-term focus (be sure, I'm not arguing either way here though I do hold an opinion). The fact is there is no legal duty for a corporation to maximize shareholder value, a couple of links:
Attempting to get the ACA repealed by posting lower than average profits (while running less efficiently, not taking all the tax breaks available, and increasing executive compensation and perks) would certainly maximize shareholder value long term.
Actually even NHS has a limit for the amount they'll spend on your treatment over time. It's rare to hit it, but any system that's trying to allocate the scare resource of medical treatment will have to stop a minority of very sick people from receiving all the resources.
Actually, the NHS doesn't have any per-patient treatment limit. They have a limit on which treatments are available on the NHS at all based on the cost-benefit ratio, which works out somewhere around £20,000 to £30,000 per quality-adjusted year of life. So people aren't forced to stop chemotherapy early, but they might be prescribed a chemotherapy drug that's slightly less effective than the very best but much cheaper. (We're generally talking very small claimed benefits, even in the studies done by the expensive drug's manufacturer to try and promote it - a lot of expensive new chemo drugs are just not that good.)
What's the financial limit? I haven't heard that before.
I know there's the NICE guidance, and then what a CCG will pay for, and what the cancer drugs fund will pay for. But those decisions almost always are about cost-effective, and not just cost.
Good point. Even if your health insurance is public, someone, somewhere is figuring out what can and can't be paid for.
One of the reasons other countries spend less on healthcare, compared to the US, is that they just don't pay for certain things (drugs, procedures, etc). The US is a bit more lax when it comes to this and that results in higher costs.
In Canada, we have a drug insurance tax (in Quebec at least, I'm unsure if this is a federal thing) so we clearly pay for drugs. I don't know the extent of what we do pay for, but surgeries and most everything is paid for by taxes.
Even breast reduction is covered if a doctor judges that it's for health reasons.
You pay for production. All of the research cost and business risk in going to market with the drug in the first place is paid by Americans. You're welcome.
Unfortunately realistic insurance claim models show that without a policy limit the insurance company will be bankrupt eventually with 100% probability. So a limit must exist or the would be no insurance business.
Insurance which covers some things is better than no insurance. Caps reduce the cost.
You might as well ask why low end processed cheese ($4.50/lb, not very tasty) is legal - why not ban it and force everyone to eat delicious artisinal asiago ($12.99/lb, mouth wateringly good) instead? Won't someone think of the poor people who aren't spending enough on dinner?
It's un-American though. It somehow feels too socialistic to just have ulimited healthcare support.
> An insurance exists to protect people from going bankrupt due to health issues
On paper, in reality it is to feed the mouths of health care insurance workers.
The level of rhetoric regarding how nationalized healtcare takes away our choice and freedom and how it brings socialism and doom to our country has always baffled me. I watched the whole thing unfold for many years now. And it wasn't just one or two people here and there, it is whole segments of population who opposed a single payer system, the industry opposed it, so that was thrown out early on.
You'd imagine we were talking about forcing people to sell their first born children or even worse confiscating their property. There were suggestions (even here on HN) of proposing some alternative back to the 1800's free market utopian version ("let's go back to the pure and glorious golden age of free markets" etc). And that would be have been interesting to see and discus if we talked about some experimental new economic system or social order. But we were talking about a basic thing that exists and existed for decades in dozens of other developed countries, which have longer living, healthier, happier people.
I meant it to be both, the institution as a whole.
The idea of "oh but what about the jobs of everyone in insurance company, think of the admin assistants and poor call center workers" has been presented before as an argument against a single payer system.
I've known for at least a decade that talc was dangerous.
I was 100% under the impression it was taken off the market years ago and replaced with corn starch.
Reading this article is the first time I realized it was not taken off the market, and I'm very confused.
How can I know this is dangerous and the company that makes it not know? I thought it was common knowledge.
I'm having a hard time expressing how perplexed and confused I am to hear talc is still on the market.
I mean, it says "not to inhale it" - how can you possibly apply it and not inhale some of it? It's impossible. There is no way to use this safely without a gas mask.
I've known about this molecular similarity to asbestos for 15 years, and have pretty much warned every barber or hairdresser that I've ever been to. They've never listened. I moved to a different city but I heard about a year ago the hairdresser at a place I used to frequent has lung cancer. Was it the cause? Who knows, but it sure is sad to hear. Regular people are just horrible about assessing / understanding risk. Baby Power is like the climate change of the local hairdressing world. That might be a slight overstatement, but gosh they sure use a ton of it here.
That's a bit excessively dismissive of the issue at hand. We've investigated many substances to death that have shown no consistent increase in risk - aspartame, coffee, most vaccines, and aluminum-oxide based antiperspirants for example. Carcinogens are a very real concern, and dismissing that concern by pretending that "everything is a carcinogen, what can you do?" is unhelpful.
> “People were using something they thought was perfectly safe,” he says. “And it isn’t. At least give people the choice. J&J didn’t give people a choice.” Among the most painful revelations, he says, was that in the 1990s, even as the company acknowledged concerns in the health community, it considered increasing its marketing efforts to black and Hispanic women, who were already buying the product in high numbers.
Cynical question: Was increasing marketing efforts to black and Hispanic women out of racism or a cold risk calculation in the hope that these women couldn't afford to defend themselves as good as other groups? Will J&J be persecuted for this discrimination?
Disclaimer: I am not from US, but by reading HN I am often surprised how things work in US.
Good example of how the system can have racist outcomes even if this particular decision did not originate in racism.
I'm sure it could have been as simple as "hey, white women aren't buying as much anymore so we should market to nonwhite women". But when you consider the overall situation it's hard to feel "relief" that some evil racist henchman wasn't behind it. The purity of your heart doesn't matter if this is the outcome.
> Cynical question: Was increasing marketing efforts to black and Hispanic women out of racism or a cold risk calculation in the hope that these women couldn't afford to defend themselves as good as other groups? Will J&J be persecuted for this discrimination?
Corporations of that size aren't usually coordinated that well, in my experience. Most likely, they were just putting marketing money in the demographics they identified in some surveys, and marketing manager responsible for that decision was from completely different department from PR guys handling the health issue.
I don't know if this is true for J&J, but the paint industry is quite large and banked on racism allowing them to get away with harmful lead additives. This kind of cold calculus is hardly out of bounds for US corporations:
The lead industry even sought to place the blame for lead poisoning epidemic on parents and children, claiming that the problem was not with the lead paint but with the "uneducable Negro and Puerto Rican" parents who "failed" to stop children from placing their fingers and toys in their mouths. Children poisoned by lead, the industry claimed, had a disease that led them to suck on "unnatural objects" and thereby get poisoned.
It does not surprise me that introduction of small particulates to any orifice on a daily basis would increase cancer risk. Household dust increases cancer risk.
The cover up orchestrated by Johnson&Johnson here, however, is the deplorable story.
I'm just a simple man, but I don't understand how a fine-grained powder, even entering the vagina, could cause ovarian cancer. This very long article spends only two paragraphs asking that question, with no answer.
Sounds like pesudo-statistical lawyering. This woman has cancer and she used talc every day of her life, ergo the talc is to blame.
One might ask why asbestos causes mesothelioma. Maybe the mechanisms are similar. Although talc is obviously less effective. But if there's increased risk, the lack of mechanistic understanding doesn't negate the evidence.
We already know why asbestos causes mesothelioma. Asbestos can form very small particles that go deep into the lung (there is good relationship between particle size and how deep it penetrates into the lung). Asbestos contains iron and the iron can promote free-radical formation, thus DNA damage and thus cancer. Yes, I'm simplifying it, but that's what I remember from my toxicology classes long ago.
I don't think it's odd to question the toxicity of talcum powder. Talcum powder used to contain asbestos, but doesn't any longer. We have good evidence that the newer talc doesn't cause lung cancer.
So an obvious question is, if talc doesn't cause lung cancer, why would it cause ovarian cancer? Of course, different tissue, different effect, but it raises doubt.
Maybe talc does cause ovarian cancer by some as-yet-discovered mechanism, but I wouldn't blame anyone for thinking it either coincidental (lots of people get ovarian cancer who never use talc) or due to something else.
I was under the impression that the cause was chronic inflammation resulting from recruitment and activation of macrophages and other immune cells to site of the fibres [1]. Chronic inflammation causes cancer on its own independent of external factors like free radical formation.
Well, I should have added details. You are correct that asbestos that doesn't contain iron can still cause cancer through a hypothesized inflammatory mechanism.
Honestly, I don't we know the exact mechanism, but have some theories that seem to fit.
And that, perhaps cryptically, was my point. Why should any chemically inert mineral cause cancer? But some apparently do, regardless. Inflammation seems most plausible.
That link says what I'm saying: it's not clear that this is really happening.
> Many studies in women have looked at the possible link between talcum powder and cancer of the ovary. Findings have been mixed, with some studies reporting a slightly increased risk and some reporting no increase. Many case-control studies have found a small increase in risk. But these types of studies can be biased because they often rely on a person’s memory of talc use many years earlier. Two prospective cohort studies, which would not have the same type of potential bias, have not found an increased risk.
Even if there is a correlation, there might not be a cause and effect relationship.
For example, it's known that female reproductive cancers are associated with the levels of various female sex hormones. Female sex hormones also affect the vaginal lining and external genitalia (in particular, moisture levels). It might be that women who are prone to ovarian cancer due to hormone levels also have a vaginal/labial situation that makes them more likely to apply powder to keep the area dry. If that were the case, you'd see a correlation with no cause and effect relation whatsoever.
(just an illustration... I'm not claiming this is what's going on, but I'd probably try to argue something like that if I were a lawyer for J&J).
However, if the coverup of the correlation is as described in the article, that would be a bad, bad thing.
I wonder if this is going to end up like the breast implant thing, with lawyers getting rich and companies in bankruptcy before we take a step back and realize the law is way ahead of the science.
Although you'd have to be a total idiot to give much attention to such a idiotic, emotive article there does seem to be evidence inhaling mico particles is very very bad.
Be it cigarette smoke or a fireplace or smog or perhaps talcum power use = mico particle inhalation.
If there's a real story here this is where it might be, or give me a better written article that is about scientists not juries.
What in fucking hell is this? An insurance exists to protect people from going bankrupt due to health issues, not to screw people over when they're already in no position to fight.
How on earth is this legal?