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I, Health Insurer

December 15, 2013
New York, N.Y.

“So you’re the people who won’t sell us health insurance.”

I was taken aback by the accusation. When you’re fresh out of college and newly employed in your first real 9-to-5 job at a famous insurance company in New York City, you expect people of your parent’s generation to congratulate you and make you feel proud. You don’t expect them to condemn your career choices in such a dismissive way. But there it was:

“So you’re the people who won’t sell us health insurance.”

I would have liked to deny it, but I could not. I wasn’t actually involved in the selling of health insurance (or, more pertinently, the refusal to sell health insurance), but I was certainly employed in the health insurance industry, and hence I was part of the problem rather than part of the solution.

My First Fulltime Job

When I graduated college in 1975, I was somewhat unfocused in my career objectives. After a few disastrous job interviews, I finally got one of the few jobs available to math majors. I was now employed at a major insurance company in New York City as an Actuarial Student.

In the decade I worked there, I was in the Individual Health Insurance Department. The word “Individual” means insurance that is purchased by individuals for themselves and their families, as distinguished from “Group” insurance, which is purchased by companies for their employees. The Individual Health Insurance Department was also responsible for Disability insurance as well as Hospitalization and Major Medical policies.

I eventually dropped out of the actuarial program but I continued at the company doing actuarial work, mostly related to product development. To sum up my job in one sentence appropriate for a resume, “I programmed and analyzed statistical studies of disability and health insurance claims, and used that data to develop new premium rates for existing policies and new policies.”

Soon after I started working, I visited my mother at her home in New Jersey. She had a guest — a childhood friend who was visiting from the Midwest. This woman had a son somewhat younger than me with a serious long-term illness. (I remember it as leukemia but my mother seems quite sure that it was instead a particularly vicious case of diabetes.) My mother’s friend asked me what type of work I was doing, and when I told her, she said,

“So you’re the people who won’t sell us health insurance.”

True enough. I hadn’t been working long, but it was long enough to know that you don’t sell health insurance to sick people. So yes, it was absolutely true. I was the people who wouldn’t sell health insurance to someone with diabetes, or at least not with a lot of exclusions. Sometimes an individual health insurance policy will specifically exclude a pre-existing condition, but if the condition often results in other health problems — and diabetes certainly qualifies in this respect — then of course the insurance company can simply decline to insure entirely.

And who can blame them? A private company selling health insurance can’t lose money in the process, or it wouldn’t be able to sell health insurance in the future.

What if one health insurance company tried to break the mold and cover individuals with pre-existing conditions? All the people with such conditions would rush to that company, and the company would experience many more claims than normal, and hence need to raise premiums, and hence make the policies less competitive to people without pre-existing conditions, leading to a spiraling up of premiums, eventually making the scheme unworkable.

Insurance and Anti-Selection

Insurance is fraught with paradoxes. Health and disability insurance is supposed to protect people against unexpected illnesses and expenses, but people have a greater propensity to purchase insurance if they know or suspect they will soon be able to make it pay off in claims. This tendency is known within the health insurance industry as “anti-selection.” (It affects life insurance as well. This is why life insurance policies generally have a two-year exclusion for suicide.)

Anti-selection affects Individual health insurance policies much more than Group policies. In Group policies, everyone at the company has the same policy, so everyone is at least healthy enough to hold down a job, and the group probably includes a bunch of young people of good health. Group insurance can be rather looser and cheaper than Individual insurance.

It’s the individuals who are the problem. Insurance companies are extremely wary of people who voluntary want to buy insurance. Insurance companies much prefer employing obnoxious high-pressure agents who sell policies to people who don’t want to buy them. People who don’t want to buy insurance are much less likely to need it or use it.

This is why my mother’s friend couldn’t buy health insurance — her family, and particularly her son (who later died of diabetes-related ailments) really needed it and really wanted it.

Health insurance companies make special efforts to avoid anti-selection, and soon after I began working, I learned of one of the most hideous methods that health insurance companies used to combat it. Here it is:

When someone first obtains a health insurance policy, it’s too expensive to review the application with a fine-tooth comb (a process known as underwriting). So generally the policy is issued without a lot of preliminary investigation.

But if a claim follows a little too quickly after issuance of the policy, then the real work begins: Much effort is spent attempting to find a misstatement on the application. This could be a deliberate misstatement or an accidental omission. It doesn’t matter. It also doesn’t matter if the misstatement directly relates to the claim or not. If a misstatement is discovered, the policy would be declared null and void, and any premiums paid would be refunded.

Of course, the sick claimant would then be left with medical bills and no health insurance policy, and very likely no chance of ever getting health insurance in the future.

Health insurance companies have a very long tradition of cancelling policies.

How High can Healthcare Costs Go?

At the time I was working in the health insurance industry, healthcare costs were rising so quickly it was difficult for insurance companies to keep up. Premiums on existing policies would be raised frequently to accommodate the new costs even though the policy benefits would remain the same.

At my company, there were still in effect a couple old Major Medical policies originally sold in the 1950s with high deductibles and high maximums. Due to rising healthcare costs, these policies had evolved into what are sometimes called "junk" policies with inadequate maximums. But premiums on these junk policies had to be raised regardless because the deductibles were met more easily. People who had these policies were very unhappy about getting premium increases with no apparent increase in benefits, but they were even more unhappy when they discovered these policies were inadequate to pay their medical bills.

It's a general rule that people who aren’t skilled in health insurance don't understand their health insurance policies, and are usually quite surprised when the policies fail to pay.

I think it was during my stint in the health insurance industry that healthcare costs rose above 10% of Gross Domestic Product, and much handwringing ensued as a result. But not everyone was dismayed. One of the actuaries where I worked wrote a paper or gave a talk somewhere that I found very thought-provoking. In the future, he said, healthcare costs might rise to be as high as 50% or even 90% of GDP, and there would be nothing intrinsically wrong with that. It would simply reflect our evolving priorities of valuing good health more than anything else in our lives.

But the idea of healthcare costs rising to 50% of GDP highlighted the fundamental flaw in the whole system: As long as private insurance companies govern who gets health insurance, there will be a perpetual class of people who will never be able to obtain it. How can we possibly tolerate an economy devoted so much to healthcare coexisting with companies that refuse to insure people who want and need health insurance the most?

The Failure of the Free Market

With healthcare, the free market has clearly failed. The United States now has the highest per capita healthcare costs in the world, but not a commensurate level of health, and many people still can’t afford or don’t qualify for health insurance.

Yet, everyone except the very wealthy ultimately need health insurance. You can’t anticipate the morning when you’ll find a scary lump or encounter a drunk driver, and few people can afford the high costs that can follow. In contemporary America It is now considered a matter of fundamental personal responsibility to purchase health insurance for one’s self and family.

What’s the solution to this failure of the free market?

In practical terms, people have found their own solutions. Many people without insurance use hospital emergency rooms as their primary source of medical care. This is not a very efficient use of medical resources, and it is one of the causes of high healthcare costs. The costs are spread out to the rest of us.

Some people dip into their savings or borrow money to pay for catastrophic healthcare costs, with the result that more personal bankruptcies in the U.S. result from healthcare costs than any other reason. Again, the rest of us pay.

Or, people who need healthcare simply go without, or delay getting a medical issue checked out for so long that it becomes a much more serious problem.

When the free market fails so dismally, the government is forced to act. We simply cannot afford to tolerate a situation where people can’t pay for adequate healthcare. Healthcare costs have really become a matter of national security.

Solutions and Conservative Solutions

It turns out that the United States already has a first-rate health insurance system run by the federal government. It’s called Medicare, and the only real problem with it is that you have to be 65 years old to qualify.

One easy solution to the healthcare problem is simply to remove the age restriction on Medicare. This is known as a “single-payer” approach, and instead of everyone collectively paying for everyone else’s healthcare through health insurance premiums (and costs that we all pay for as a result of people without health insurance using hospitals ERs or going bankrupt), we instead pay for healthcare in a more equitable and efficient way though taxes.

Of course, a considerable proportion of the American public feels that the federal government should not have so much jurisdiction over these things, so other solutions are sometimes proposed.

In 1989 and 1992, the well-known conservative think-tank The Heritage Foundation released two studies, “Assuring Affordable Health Care for All Americans” and “The Heritage Consumer Choice Health Plan,” which described approaches to health insurance that preserved the role of the free market, and hence appealed to conservative ideology. The Heritage Foundation recommendations involved requiring health insurance companies to make available policies with certain minimum standards and covering pre-existing conditions, but also require everyone to purchase health insurance, much like everyone who operates a car is required to buy automobile insurance.

It’s certainly not as elegant as single-payer “Medicare For Everybody,” but it seemed to be a reasonable conservative approach that retains a dominant role for the private-sector health insurance industry. Policies are required to cover pre-existing conditions, but there’s no anti-selection because everyone is required to buy health insurance.

Another essential guard against anti-selection is a uniformity of benefits. Medical costs that are more elective than others — such as pregnancy — can’t be optional because people planning a pregnancy would get the extra coverage before conceiving, and then drop the coverage after delivering. Such coverage must be mandatory for the system to work.

In 2006, Republican Governor Mitt Romney signed a bill implementing the Heritage Foundation approach in Massachusetts, and in 2010 the Heritage Foundation approach was adapted for nationwide use (but still administered by individual states) as the Patient Protection and Affordable Care Act, known popularly as Obamacare.

Insurance and Fear

By the summer of 1985, I was getting so much freelance work from PC Magazine that I quit the insurance company, and I’ve been self-employed ever since. Prior to leaving, I had the opportunity to convert my group coverage into an HMO, and even though that HMO eventually became part of another company, I’ve kept the same policy all these years. Since 1985 my premiums have increased annually, and they are currently $869.18 a month. My wife (also self-employed) has insurance through a different carrier, and her premiums are even higher — so high, in fact, that she is embarrassed that the amount be publicly revealed!

Could we have done better over these past years by utilizing the free market and shopping around for cheaper health insurance?

What stopped us, of course, was basic fear. Different doctors are members of different insurance networks, so changing insurance policies could result in losing a familiar doctor. And the older one gets, the more the pre-existing conditions accumulate. I’ve had two shoulder surgeries in recent years. If a problem related to these surgeries developed in the future, would another insurance company consider that a pre-existing condition? I’d rather not find out!

Does this even qualify as a “free market”? I don’t think so.

For these reasons, I’ve simply kept the same policy since 1985 as the premiums steadily increased to $869.18 a month.

This is What a Free Market Looks Like!

The Affordable Care Act has changed the rules, however. I thought I’d be keeping this same policy in the future simply out of inertia, but like many people, I discovered this was not to be. Much to my consternation, my policy will be cancelled at the end of 2013, and I had to get on the web to find a new one.

Fortunately, I live in a state whose government has tried to help its citizens obtain health insurance rather than hinder them, so I got on our local health insurance exchange (nystateofhealth.ny.gov) to find another policy, and the whole process turned out to be only occasionally rocky.

The exchange is quite amazing: Policies are listed side by side with benefit descriptions and premiums. I have never seen anything like this. Even when I was working for the insurance company, it was extremely difficult to obtain tables of premium rates charged by other companies.

Now this is what a free market looks like!

It turns out that I can get a Platinum (i.e., no deductible) policy for as low as $443 a month, and even the highest — an $896 outlier; the second highest is $621 — is just a little bit more than what I’ve been paying in 2013. Wow!

This is a time to be proud. For the first time in this country, we have the beginnings of a system to provide for universal health insurance coverage. It’s not single payer, and it doesn't address many of the problems discussed in Steven Brill's essential cover story in Time on healthcare costs, but it’s certainly a step forward.

And no one can ever again accuse anyone else of being “the people who won’t sell us health insurance.”


Comments:

Charles,

A brilliant explanation of, as well as your personal insight into an industry that has defied understanding by the vast majority of the American public. A very well written piece.

Walter Meyer, Sun, 15 Dec 2013 16:52:05 -0500

Thanks! — Charles

Excellent! This was exactly what happened to me my very first year out on my own. I was 20 and in my first year of college in NYC. I had health insurance but honestly can't remember right now through where, it had to have been an individual policy. I went to see a dermatologist my school had sent me to. This was my first attempt to use the insurance. I got a phone call a few weeks later, a woman from the insurance company (who was VERY nasty ) said to me, "You lied about a pre existing condition and not only will we not cover you for your doctor visit but we are dropping your insurance. We don't do business with people who lie." I told her I was 20 years old and in school and asked her what they thought I was lying about. She said that I failed to tell them I had a preexisting skin disease. I told her I never had a skin disease. She said, you had acne as a teenager and you said so on your doctors intake form. THAT IS a preexisting skin disease. She spoke to me as if I were the lowest kind of criminal. I didn't have insurance again until I had to apply for medicaid at age 30. No one would take me as ANY preexisting problems immediately disqualified me.

— Jennifer Kellow, Sun, 15 Dec 2013 18:02:48 -0500

The United States does not have a free market in healthcare by any stretch of the imagination. The current market is a product of government regulation and regulatory capture by the insurance industry.

— David in San Jose, Mon, 16 Dec 2013 01:41:31 -0500

Liked.

— Bill B, Mon, 16 Dec 2013 12:34:10 -0500

Charles- thanks for a great explanation of why you see the Affordable Care Act is a step in the right direction. It would be nice to see this type of reporting happening from our major news providers as well.

— Scott, Mon, 16 Dec 2013 12:52:20 -0500

Looking forward to your appearance on Fox News. :-)

— Alek Davis, Mon, 16 Dec 2013 13:32:49 -0500

"But if a claim follows a little too quickly after issuance of the policy, then the real work begins: Much effort is spent attempting to find a misstatement on the application. This could be a deliberate misstatement or an accidental omission. It doesn't matter. It also doesn't matter if the misstatement directly relates to the claim or not. If a misstatement is discovered, the policy would be declared null and void, and any premiums paid would be refunded."

When ineligible customers pay for policies whose benefits will always be denied, the insurance company only investigates a few of them and refunds a few of them. Those ineligible customers who paid but who didn't have claims don't get investigated, they don't get refunds, and the insurance company keeps premiums that it isn't entitled to.

I discovered that an insurance policy had been paid where the supposed covered person wasn't eligible. I asked for a refund. The insurance company refused to pay a refund. They said that, hypothetically had the supposed person had a claim, the insurance company would have paid it. I think they were lying. Exactly as you say, if a claim had arisen they would have denied the claim and only in that case would they have paid a refund.

— Partly ripped off too, Mon, 16 Dec 2013 23:13:47 -0500

Good piece, Charles. Inspiring!

Bob Reselman, Tue, 17 Dec 2013 21:59:22 -0500

1. "With healthcare, the free market has clearly failed."

2. "Now this is what a free market looks like!"

You confused me. So, does ObamaCare is cool because it finally introduced free market to healthcare? Or because it removed it from failed free market?

— Alien, Thu, 19 Dec 2013 17:00:40 -0500

Your insight into the inner workings the health insurance industry is interesting, but:

"With healthcare, the free market has clearly failed."

There has never been a free market in health care. Using the term "free market" in the context of ObamaCare is such a distortion of that term that I don't even know where to start with how much is wrong with it. To use the term "free market" to describe one of the most regulated industries in the US (even BEFORE ObamaCare) is disingenuous. I'm disappointed to find that the clarity of thought you display about software is lacking in your discussion of politics.

Chris McKenzie, Fri, 20 Dec 2013 17:25:53 -0500

If you're buying a car, you can compare features and prices of the various cars on the market, and the reputation of the companies that sell them. You use this information to choose a car to purchase. We call this process a "free market" even though the features of automobiles are highly regulated.

With the Affordable Care Act, we can now compare features and prices of health insurance policies, and the reputations of the companies that sell these policies. This is something that individuals were not able to do previously. Despite the underlying infrastructure of regulation, I think it's legitimate to apply the label of "free market" to this process.

Certainly from the consumer's standpoint, the health insurance market is freer than it's ever been, and the consumer is also free from anxiety because there is an assurance that the policies meet a minimum standard. — Charles

If you don't like any of the cars for sale, you don't have to buy one at all. I think that's an important part of why we say there's a free market in cars.

I agree with Alien that you seem to be using two different definitions of "free market". When you say that the free market failed, you're talking about the fact that people didn't have to buy health insurance. When you say that there's a free market now, you're talking about the fact that it's easier to compare different health insurance policies. (Presumably, it was possible before, if harder. Or did insurance companies actually expect you to sign up for a health insurance policy without knowing what you were getting or how much you'd need to pay for it?)

Freedom from anxiety is nice, but doesn't really have anything to do with free markets one way or the other. A completely centralized economy that provided sufficiently for everyone's basic needs would also eliminate anxiety, but obviously wouldn't qualify as a free market.

I have a question for Chris McKenzie, if you're still reading: You say that there has never been a free market in health care. Do you think there should be one? If there were one, do you think everyone would be able to afford health care, or do you consider it acceptable that those who couldn't afford it wouldn't get it, the same way that those who can't afford a car don't get one?

— Y. E., Tue, 31 Dec 2013 07:23:59 -0500

How do you think doctors would react if your solution to open up Medicare to everyone was taken and ALL doctors were reimbursed for ALL services they perform at Medicare rates?

Steve S, Tue, 31 Dec 2013 14:09:27 -0500

I dunno. Emigrate to Canada? — Charles

$443 a month. WOW. "This is a time to be proud."

Here in the Netherlands a health-care package is mandatory, we have a free market too, and packages range from 68 euros ($93) to a little more than 100 euros ($138) a month. It's far from perfect, but packages starting from $443.. wow.

— Robin, Tue, 31 Dec 2013 15:27:22 -0500

According to this handy chart:

List of countries by total health expenditure (PPP) per capita

per capita healthcare costs in the Netherlands are about $5000 a year, or about $400 a month, so obviously the low monthly premiums pay for only a fraction of total healthcare costs. — Charles

I am a 65 year old man that has been paying for health insurance for 35 years. In this past year, my health insurance plan has been canceled and I was forced to purchase health insurance that costs triple what I was paying and has a deductible that is twice as high.

I went from $250 a month, $2500 deductible to $800 a month $6000 deductible. I hope that you sir are also "proud" of this.

— Don, Tue, 31 Dec 2013 16:24:18 -0500

At the age of 65, you become eligible for Medicare. — Charles

"With healthcare, the free market has clearly failed."

The free market hasn't been involved in healthcare in this country in a very long time. There is no realm of possibility where your statement makes any sense; healthcare is one of the most heavily regulated industries in the US. The reasons healthcare is so expensive is because there is no free market. It's so burdened down as to be almost unworkable.

We'd be better if insurance was not offered through employers at all. What sense does it make to have your health insurance tied to your job? Of course, that is also the fault of government regulation. During WWII, the federal government instituted wage controls, so employers started offering greater fringe benefits (mainly healthcare) to attract employees since they were disallowed by the government to engage in commerce freely. Unfortunately this system survived the war.

Mandatory insurance is also wrong. People should not be required to buy a product, any product, no matter how good other people think it is for them. I'm 26 years old. I have no health problems. Paying thousands of dollars a year for health insurance is a poor choice. I'd be better off investing the money now, and only using it if I actually needed it. I'd also be better off if all the money my employer has given me in the form of fringe benefits had actually been given to me in real dollars. Again, invest and use when needed. I wasn't able to make that decision for myself, however, because the government has already decided what was in my best interest.

Long story short: government interference is directly responsible for higher healthcare rates. You want affordable healthcare? You don't need mandatory insurance, just get the government out of the way.

— J.J., Tue, 31 Dec 2013 17:37:27 -0500

Thanks for the thoughtful write up. Though I think it's not intrinsically the free market itself that's failed, but the capitalist-driven insurance market.

When a corporation's only goal in life is to maximize profits, and there's little-to-no negative feedback when you simply don't provide coverage to groups of people, what is the end result? A systematic refusal to offer payouts.

The capitalist insurance game is an exercise in cheating people who are unlikely to need the insurance, and refusing to sell it to people who probably will need it. Sorry for the crassness of the word "cheat" but that's what it is. Imagine for a moment and electrical grid where companies could simply refuse to run lines to small rural areas. What would the United States look like to the rest of the world if 15-20% of it's citizens didn't have adequate access to affordable electricity. Or postal mail. Or long-distance phone lines.

Oh, look at that, we already have models of services that a modern nation considers essential for effective development and human welfare ... and they're delivered fairly effectively using a hybrid private/regulated framework.

— Colin, Tue, 31 Dec 2013 17:51:51 -0500

Charles, I guess you're joking about doctors moving to Canada. I don't know what people who are currently doctors would do, but I'd imagine that, of people who are still deciding on a career, fewer would choose to become doctors if they knew they'd make less money. That couldn't be good for the availability of healthcare in the future.

J.J., would your get-the-government-out-of-the-way system provide affordable healthcare for everyone, or just for healthy 26-year-olds?

— Y. E., Thu, 2 Jan 2014 02:05:48 -0500

So you're suggesting that the medical profession will now attract idealistic young people who want to do good in the world rather than people in it only for the money? — Charles

Y. E.

Healthcare would be cheaper for everyone, regardless of age, gender, race, or whatever qualifier you want to come up with. Look up how many different codes there are for hospitals to deal with. It's become a paperwork nightmare requiring a high ratio of support staff to medical care providers than would be needed otherwise. Compare practices that don't accept insurance/Medicare/Medicaid and you'll typically see much higher efficiency and higher quality of care (such as doctors actually being able to spend more than a couple of minutes talking to you before having to make more rounds).

You also have to take into account all the legal favors the government does for large drug companies. Vaccine companies can't be sued, long-lived patents, FDA approval required for drugs even if they have already been proven in other countires, etc.

It's a big reason why medical tourism is even a thing. I can stay in America and get heart surgery, and it can set me back over $100,000. Or, I can get in a plane, fly to India, and have it done for a couple of thousand plus a couple more for airfare and hotel stays. One of those is in range for most people, albeit for some it would still be a hardship. The other one is completely out of reach, sadly.

If you really want to use the power of government to do something (which usually isn't that great of an idea), require all health providers to publicly display their prices. In their office, on their website, wherever they have a presence. Hospitals have a huge range of prices with no real explainable differences, besides the fact they can (based on Medicare data). Right now, there is no good way for customers to compare prices at hospitals, so they don't really have to compete with each other in that regard. It's worked pretty well for a hospital in Oklahaoma in getting customers and exerting downward pressure on prices at other hospitals near them: http://kfor.com/2013/07/08/okc-hospital-posting-surgery-prices-online/ Of course, they don't accept Medicare/Medicaid patients because of the Federal hang ups that come with accepting their money.

It's nice that people want to help, but unfortunately we aren't very smart about it. Medicare/Medicaid fraud/waste/abuse is pretty well-known and widespread, and unfortunately that kind of thing won't go away any time soon or be any better once Obamacare is enforced. People have no idea if they really need to be xrayed for the 12th time that year, or any other tests done that they don't really need, and hospitals will be happy to stick taxpayers with the bill. But when it comes down to spending your own money on something, instead of it being abstracted away by insurance, you ask a lot more questions.

— J. J., Thu, 2 Jan 2014 12:05:50 -0500

> when it comes down to spending your own money on something, instead of it being abstracted away by insurance, you ask a lot more questions.

Questions like "How am I going to pay for this?" — Charles

> when it comes down to spending your own money on something, instead of it being abstracted away by insurance, you ask a lot more questions.

Questions like "How am I going to pay for this?" — Charles

Exactly questions like that.

That's the point.

Some people may elect not to get certain procedures or tests done, and their total bill will go down.

If you think making sure every single person is taken care of and they can have access to any and all treatments regardless of their ability to pay and you also think government force should be used against everyone else to make them pay for it, fine. I don't think that's a great idea, but fine. There's much more efficient ways to do that though.

Direct cash payments, take every dollar directly off how much taxes they owe (similar to Earned Income Tax Credit), etc. Anything but forcing compliance with myriad state and federal laws which drives up the price of healthcare and encourages fraud in order to make up for mandated fix prices, and then, after your policies artificially jack up prices, try to subsidize it because it cost too much. It's madness. Just remove the bureaucracy, and if you want to foot the bill, foot the bill.

— J.J., Thu, 2 Jan 2014 18:03:14 -0500

> So you're suggesting that the medical profession will now attract idealistic young people who want to do good in the world rather than people in it only for the money?

I'm suggesting that the number of idealistic people plus the number of people in it for the money is greater than the number of idealistic people. I can't imagine that idealistic people who want to do good in the world would decide not to become doctors just because it pays well.

— Y. E., Fri, 3 Jan 2014 22:44:56 -0500

J.J. wrote:

"It's a big reason why medical tourism is even a thing. I can stay in America and get heart surgery, and it can set me back over $100,000. Or, I can get in a plane, fly to India, and have it done for a couple of thousand plus a couple more for airfare and hotel stays. One of those is in range for most people, albeit for some it would still be a hardship. The other one is completely out of reach, sadly."

For most people, both are out of reach. The population of India is larger than the population of the U.S. Even if you ignore the rest of the countries on the planet, most people have a level of income that can't afford heart surgery in their own country, India.

Medical tourism is a comparatively free market, but maybe humanity would be helped by making it more attractive for doctors to serve their own fellow citizens before they serve medical tourists.

— Partial, Sun, 5 Jan 2014 20:44:10 -0500


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