• Doctors, not Obamacare, will ask you about your sex life

    When I was a medical student, my teachers explained that – as physicians – we would be privy to people’s most private information. They would tell us things about themselves that they might tell no other human being. It was stressed that this was an honor, something to be noted and respected. We would keep those things secret, both by law and by social contract.

    Sometimes, we would have to ask them questions about awkward things. During my month of adolescent training, we spend a large amount of time learning how to talk to kids about drugs, depression, eating disorders,violence,  and – yes – sex. We learn to do it because it’s our job. We’re trying to keep people healthy, and all of these things are inherently risky. If they are occuring, we want to talk to adolescents about how to protect themselves and take care of themselves.

    As an adult, when I go to a checkup, my doctors still ask me about my sexual health. They ask if I’m sexually active. The best among them have the courage to ask if I’m sexually active with anyone other than my wife. Why? Not because they’re prying busybodies; they ask because having multiple sexual partners greatly increases your risk of sexually transmitted infections. They’re looking out for my health, and want to advise me best on how to manage it.

    Understand, please, that I can refuse to answer these questions. I can also lie. How would they know? But lying about my sexual activity to my physician would be akin to lying about my aches and pains. If I don’t tell the physician what’s going on, it’s hard for him or her to help me.

    This is the way it’s always been.

    So take this piece by Betsy McCaughey with a grain of salt:

    Are you sexually active? If so, with one partner, multiple partners or same-sex partners?”

    Be ready to answer those questions and more the next time you go to the doctor, whether it’s the dermatologist or the cardiologist and no matter if the questions are unrelated to why you’re seeking medical help. And you can thank the Obama health law.

    “This is nasty business,” says New York cardiologist Dr. Adam Budzikowski. He called the sex questions “insensitive, stupid and very intrusive.” He couldn’t think of an occasion when a cardiologist would need such information — but he knows he’ll be pushed to ask for it.

    The president’s “reforms” aim to turn doctors into government agents, pressuring them financially to ask questions they consider inappropriate and unnecessary, and to violate their Hippocratic Oath to keep patients’ records confidential.

    Evidently Ms. McCaughey knows some pretty crappy doctors, because if you consider it “inappropriate and unnecessary” to talk to your patients about their sex lives, then you really shouldn’t be in the business. I agree that it’s not necessary to ask these questions at every visit for every complaint. But seriously, a cardiologist is saying he can’t imagine a single occasion when he might ask a patient about his sex life? Really? I’m speechless.

    But it gets worse. Ms. McCaughey further misrepresents what the law does:

    Embarrassing though it may be, you confide things to a doctor you wouldn’t tell anyone else. But this is entirely different.

    Doctors and hospitals who don’t comply with the federal government’s electronic-health-records requirements forgo incentive payments now; starting in 2015, they’ll face financial penalties from Medicare and Medicaid. The Department of Health and Human Services has already paid out over $12.7 billion for these incentives.

    There are federal EHR requirements. But those are part of the HITECH Act (which was part of ARRA), not Obamacare. What Obamacare introduces is that insurance must now reimburse physicians for preventive services. These include things like STI counseling (which is why more docs may ask about sex). They also include lots of other stuff, especially for women and children. I’m fine with this, because these things work. They have evidence behind them. That’s why they’re in there. For years, we’ve paid for tons of things that don’t work, while not paying for things that do. This tries to right that balance.

    But, hey, if you don’t do those things as a doctor, you won’t be “penalized”. You won’t get paid for them, and your patients might suffer, but no Obamacare thugs will come to get you. Moreover, there’s nothing in the law that mandates that the answers to your questions be sent anywhere or to the government. They’re part of your medical record, as they always have been, and they’re protected by the same laws that have always protected your data.

    There are legitimate reasons to dislike Obamacare. It amazes me how opponents of the law keep needing to invent ones that aren’t accurate in order to rail against it.


    • Thanks, Aaron. I can promise you the social/sexual history we learned how to take last week in medical school is not a new part of the curriculum — to say the least.

      • Thanks! I just heard her commenting on this on the Lars Larson show on my way home this evening. This completely infuriated me. I have been a nurse for over ten years and of course physicians should be able to ask these questions. The rise in HIV and STD’s in only continuing to increase, and yes, sexual health is also apart of this complex healthcare system that individuals have. I truly don’t doubt that some people will not be truthful but this is their choice. Population health is an issue that has to be addressed.

      • Just lie that what I plan to do if the questions are not relevant to my visit to a doctor in the future

    • The New Republic, Jonathan Cohn’s magazine, has yet to get over the embarrassment of having published Ms. McCaughey’s fictional account of the Clinton health care reform plan, which was instrumental in defeating the Clinton plan. Indeed, the then editor of The New Republic later admitted that he knew McCaughey’s account was fictional but published it anyway “as a provocation to debate”, refusing to acknowledge that his own opposition to the Clinton reform (he later opposed the Obama reform) was the real reason he published it. The subject of health care makes many otherwise intelligent people very stupid.

    • I’m trying to figure out this bizarre aversion that McCaughey has to any sort of guaranteed health insurance coverage in the US, going at least as far back as the Clinton plan in the early 90s. I’d claim it has to do with her being an industry shill, but her attacks have been so repeated and outlandish that it almost seems… personal.

      I guess maybe when you spend so much time working for Big Tobacco, you lose all sense of reality.

    • It often seems to me that I spent 20 years talking to people about sex. I actually used to think about getting some training as a sex therapist since sex questions and sex problems were such a huge part of the primary care job. Betsy McCaughey should shoot me an e-mail and I could set her straight.

      My biggest complsint about O’care is the endless parade of ridiculous arguments against it. Too many pages! Only 17 years of debate! Too many Democrats and not enough Republicans! Contraception! Death panels! I don’t know why the other side refuses to produce more meaningful arguments

    • Cardiologists do ask about sex. Mine does. All of the ones I work with do. Heck, way back when I went to medical school we were taught to ask about sexual activity. Most of us familiar with McCaughey’s work wont be surprised at this.


    • Um… Doesn’t every Viagra, Levitra, etc commercial tell patients to talk to their doctors if they takes nitrates for chest pain? I thought chest pain was a cardiologists stock in trade?

    • In your haste to criticize the critic, you missed the bigger point: That physicians who practice “consensus medicine” aren’t doing their jobs. I can get on the Internet and read that stuff for myself; what I want is to be treated by an individual who uses his brain to solve difficult problems I can’t solve on my own. Filling in blanks on an EHR screen doesn’t further that cause. If a physician needs the information, he or she will ask for it without being told by a bureaucrat or computer system.

      As to whether ACA mandates particular questions in the taking of a medical history, there is in fact a lot of confusion about which of the pieces of legislation does what. But it is beside the point: Both are big-government interventions into the private affairs of individuals that should not be happening.

      This information should be handled on a “need to know” basis; and bureaucrats, whether government or others, have no need to know; at least, not a need to know that should override one’s basic privacy rights. If a physician NEEDS to know your sexual history, fine — he or she can ask the question and you can decide how you want to answer. But it is not acceptable to have the question asked because “Yes, it is irrelevant, but I have to put something in the blank”, which is a totally different standard, and one that Americans who respect their privacy ought to react angrily to.

      A related issue is the entire concept that easy sharing of medical information is a good idea. With 20 years in the business of implementing various types of health care information software systems, I say it should not. The security of these most private of data is only as strong as the weakest link, and there are many, many weak links in these systems today.

      The so-called “meaningful use” guidelines are a perfect example of what we can expect going forward. A true bureaucratic “solution” to a problem that didn’t exist in the first place. Without getting into the technical details, meaningful use is just as superficial as we would expect from government.

      Finally, the fact that taxpayers had to PAY physicians to acquire EHR systems speaks volumes. The systems had not adequately evolved and the kickbacks to providers have been a total farce. If the systems were really that good, you wouldn’t have had to pay providers to take them. As usual, when government starts blowing taxpayer dollars, there are people standing in line to collect, and unfortunately, doctors and software developers are no exception. Some of the worst software I’ve seen in my lifetime is currently in use in medical offices as a result of yet another taxpayer boondogle.

      • Without endorsing the use of EHRs, I think it is wrong to say that they would be adopted without financial incentives if they were good enough.
        The problem is that human beings are creatures of habit. They do what they’ve always done. Physicians are not magically exempt from this rule. A large, short-term advantage to using EHRs might be powerful enough to overcome that inertia without financial incentives. Smaller, more long-term advantages would not be.

        • Well yes, of course, if there was ever a group of people reluctant to embrace technology, it would be physicians. Not. Who wouldn’t want to pay a couple of million dollars for a system that cuts your productivity by 30-50%? The problem with EHR — and I say this as a software engineer turned physician — is that they stink. Epic’s informal motto is “We suck less”.

        • “Without endorsing the use of EHRs, I think it is wrong to say that they would be adopted without financial incentives if they were good enough.”

          And so what if they are not adopted? Why is that not something a private doctor can decide for themselves? Why do people in this country hate individual freedom so much (which includes an individual doctor using his freedom to choose how to keep his records)?

          The question should not be:”how Star Trek-y does my doctor’s office operate?” The question should be “does my doctor do his job, even if it is with paper records?”

          If your doctor does his job, what do you care how he keeps his records?

          • ” Why do people in this country hate individual freedom so much (which includes an individual doctor using his freedom to choose how to keep his records)?”
            And why wouldn’t doctors have the freedom to keep no records at all? Why would we be afraid of that?

      • You are so so correct . It is NONE of the government’s business
        what you, as a patient, discuss with your doctor

        What is with all of these controlling busy bodies in government
        anyway ? Tell them to mind their own business and TRY to
        enjoy life as one among equals .

    • My answer to an electronic record will be “sheep”.

      Sexual orientation? Sheep.

      How many partners? Sheep.

      How often? Sheep!

      What the hell does a dermatologist care?

      Electronic records are not protected by any sort of privacy protection. Anyone who provides the answers for some condition not directly related to a sexual problem/condition is a fool.

    • I think Aaron and most of the comments posted here are overlooking the possibility that your answers to these questions – and I do agree that asking about sexual activity/health is a reasonable enough topic in many healthcare settings – may be available far beyond your own doctor. As I understand it (and correct me if I’m wrong) but one of the key features of electronic health records is that they can be accessed quickly and easily by people other than your own doctor. I think we can all understand why in some cases that’s a good thing, but at the same time the idea that your local social worker can access your electronic health records and find out the details of your sex life – well, that’s going a bit too far in many people’s eyes.

      Ms. McCaughey gets some details wrong – for example, just paying cash probably isn’t sufficient to keep this information out of the EHR or either insurance company or government hands, it looks like you need to affirmatively request it not be included, and that may still not be enough. For this reason, I’d recommend anyone seriously concerned about the issue stick with cash-only doctors, who generally aren’t going to represent the same privacy concerns as doctors that are in the insured/third-party payer system.

      • In the course of doing software development over the last 20 years, I can tell you that I have personally had access to personal details of hundreds of thousands of patients. Yes, we have HIPAA agreements that legally prevent us from disclosing this kind of information. But if anyone claims that data is inaccessible, they’re lying. Almost daily I have seen intimate details of people’s medical lives, and there is quite literally no way to diagnose and solve computer problems without access to those data. Obviously, professionalism should stop people from sharing that information, but there are millions of EHR records stored on hosted file servers today where that data is accessible to large numbers of people. Credit card processing systems are far more secure, yet, there have been repeated instances of that data being made public. Credit cards can be cancelled; your medical history cannot.

        In dealing with problems, we commonly communicate with other professionals, e.g., claims processing facilities, labs, other software developers, bridge developers and any number of other individuals who also have access.

        Various facilities and provider offices have personnel with complete, unfettered access. For the most part this is because these systems weren’t given the proper amount of time to evolve before being pushed on providers by the taxpayer kickbacks and the Medicare “incentives” and future docking of fees.

        There is little doubt that physicians would eventually have made this transition without taxpayer kickbacks. But it would have been done on a schedule that made good fiscal and financial sense (this is part of the magic of free market business decisions).

        When these systems are well-designed and implemented, they will provide efficiencies that make it a sensible decision to make the investment. They’re getting there, but they aren’t there yet. Anyone who claims these data are secure at this point in time is either misleading the audience or exceptionally naive.

    • Mr. Carroll’s blanket assertion that “there’s nothing in the law that mandates that the answers to your questions be sent anywhere or to the government” is either disingenuous, or dangerously naive. As Stackpointer noted, Obamacare has yet to be fully understood — and it is but one law among many that mandates where our sensitive private information must be sent. Even if it’s not the case yet, is Mr. Carroll willing to bet that some future law will not mandate that our medical records be sent to Washington?

      One need not be anti-Obamacare to understand that this opens a whole new level of potential government snooping.

    • You are certainly better off keeping your information out of an electronic health record. Unfortunately, this is not up to you. If your health care providers use such records, they will be unable to avoid incorporating your information. They will not have an alternative record keeping method.

      You could try to seek out those who do things the inconvenient old fashioned way, but with federal mandates these will become fewer and farther between.

      Can the feds see your records? Absolutely! Look it up. It is part of standard PHI training that various federal entities can see whatever they want of individuals’ records. They could see the paper records as well, but this is obviously more complicated than just reviewing computer files.

      You might believe that the federal government would not read individuals’ medical records, but if so, you probably still believe that the NSA is not spying on you.

      • I’m not sure that the number doing it the ‘old fashioned way’ are going to be fewer and fewer. The number of cash-only medical practices seem to be growing (although still a small minority), and few if any of them will be adopting EHRs that the government can access (most seem to be sticking with paper, those adopting EHRs aren’t exactly embracing the idea that they need to allow anyone outside of their office to see the records).

    • As for responding to the questions: probably no need to lie. If it is required on a form, perhaps that would be the only alternative. If asked in person just say you will not answer. Your provider might treat you to a misinformed lecture about the protection of your health information, but there is nothing they can do. If the answer actually is relevant to your particular condition, they might explain why, and you might consider answering.

      If you want information to be “protected”, do not allow it to enter your medical record.

    • The number of cash only practices may be growing, but there are so few patients who can afford healthcare without insurance that the number of practices using EHRs will grow as long as it is mandated.

      Paper records are far from perfectly secure, but they are way better than EHR.

      • ” but there are so few patients who can afford healthcare without insurance that the number of practices using EHRs will grow as long as it is mandated.”

        One of the greatest propaganda tools of the pro-Obamacare forces was the use of the term “health care” as a stand-in for the term “health insurance”. In this instance, we’re talking about physician services as though it were the entire health care picture.

        Most people can afford to visit a physician as needed, even if paying out of pocket and in fact, health insurance covering small expenditures (like physician visits and contraception) is a total corruption of the concept of insurance (which was developed fundamentally for risk management). This change from “insurance” to a “payment system” is no small contributor to the basic problem of overall cost of the health care system.

        EHRs are mandated only in the sense that government will short pay you for services billable to Medicare. But financially aware physicians know that Medicare is a losing proposition for them anyway; further cuts are just further incentive to bail out of the program.

        Use of EHRs will grow, not because of the mandate, but because the software will get better and the cost of systems will stabilize, while younger physicians are trained on EHR from the early days of Med School. It was a mistake, however, to push EHR on physicians who are more willing to retire early than adapt to a bad system of record keeping.

        The number of physicians opting out of Medicare has doubled since 2009 and will result in tens of millions fewer Medicare encounters than there otherwise would have been, even as we’re ramping up the number of Medicare patients. There are lots of reasons this has happened, but it was totally predictable and predicted as a result of both the EHR mandate and Obamacare.

      • That’s not even vaguely accurate. Most people can afford primary care out-of-pocket on a cash-only basis, and with some intelligently designed safety-net programs those that struggle to pay even for basic, low-cost care could do the same (think food-stamps). It’s not at all uncommon for doctors that are cash-only to charge less than some co-pays, see this doctor in Texas: http://theselfpaypatient.com/2013/09/11/for-less-than-many-insurance-co-pays-this-doctor-in-austin-texas-will-see-you/

        Specialists and hospital care are a bit tougher, but given that most people are likely to end up in high-deductible plans even with Obamacare, I’m not sure why there’s much difference in paying $6,000 a year for insurance and having to pay $6,000 out-of-pocket for $12,000 worth of care, and just paying the $12,000 to the hospital/doctor. Especially when by paying cash you can probably save money and pay less than $12,000.

        Self-pay healthcare doesn’t work for everyone or every treatment, but it works for an awful lot of people and treatments. And usually at a big savings over the current third-party dominated system.

        • Going without insurance works for most people. Most people won’t get a catastrophic disease/injury that leaves them needing 1/2M$ of medical care. But that’s not why people have insurance.

          I knew someone, a healthy, young guy who did without insurance. He was hiking, got bit by a rattlesnake, and the bill had topped $100,000 by the time he woke up from his coma, because doctors had been working day and night to save his hand from amputation (which they did). Needless to say, he didn’t have $100K in his bank account. He worked out a payment plan with the hospital and was paying the debt for years.

          I knew a family with a kid born with a defective heart valve. He was a healthy kid, star of his Little League team, but he’d had several open heart surgeries already and a few more in his future. His family had excellent insurance.

    • Specialists and hospital care are not “a bit tougher”, they are completely beyond the means of all but the very wealthy. Everyone else, including many in the 1%, need insurance.

      This has nothing to do with whether you like or dislike the ACA. It is just a matter of how expensive health care has become. Yes, you may be able to find someone who can do outpatient primary care, and share with the patient the savings from avoiding insurance filing rules. But that is all they can do. If you are sick enough to need hospital care, as nearly all of us will be eventually, then the cost will break the bank.

      Plus, individuals have nothing approaching the knowledge o health care or costs to do their own negotiating once it becomes more complicated than a simple outpatient visit.

      • “It is just a matter of how expensive health care has become.”

        It is worth thinking a bit about WHY health care has become so expensive. Some argue that technology is the cause, but that makes no sense at all: the one thing in every area of technology that is pretty consistent is that it gets cheaper over time, and costs of new technologies, while high, quickly drop as the market expands. Others claim it is “insurance company profits” — an industry that typically makes less than $20 Billion a year, total — a mere fraction of the waste alone in Medicare!

        So, what is the cause? One thing worth considering is the fact that in the 50s and early 60s few people had any trouble paying for their health care. I recently saw a hospital bill from 1955 for the delivery of a baby, including the circumcision, that was $69.

        There is nothing shocking here. When government took over half of the health care economy beginning in 1965 and imposed priced controls, the market influences in health care were undermined. Practically every major study of the subject has found that cost-shifting to cover short-pays by government have caused costs to increase. It isn’t practical for government to do health care without price controls, yet, they always destroy markets. So, we shouldn’t be astonished that now, 50 years later, costs are out of control.

        Today Buffett stated it clearly: That costs are a tapeworm destroying our economic body, and that tapeworm must be killed. The starting point is to kill Obamacare. Doug Elmendorf spoke very clearly on the subject today, as well — Medicare/Medicaid and the subsidies under Obamacare make our long-term budget “unsustainable”. Long term being 30-40 years, which isn’t very long at all if you’re a 20-something planning for retirement on part-time wages as a result of Obamacare economics.

        • “It is worth thinking a bit about WHY health care has become so expensive.”
          Apparently it’s worth thinking about but not worth reading any other blogpost on this site. Try clicking on the tag “costs” and reading those.

    • Again, this just isn’t correct, at least not for all or even most cases. I write about them frequently on my blog. You don’t need to ‘negotiate’ prices with a hospital any more than you negotiate the purchase of your lunch at a restaurant, if the prices are posted clearly. Not many hospitals do this, but some do, and I expect it to become easier as more do.

      Check out the prices at Surgery Center of Oklahoma: http://www.surgerycenterok.com/pricing/ I don’t believe there’s a single procedure listed there that is more than what the average family pays in insurance premiums each year. Obviously there are some things that greatly exceed these prices – some cancer treatments come immediately to mind. But it’s foolish to pretend that people can’t shop for care when that is precisely what many people are doing. If they weren’t, the medical tourism industry wouldn’t exist, not to mention this guy: http://theselfpaypatient.com/2013/09/09/thyroid-cancer-specialist-talks-about-being-cash-only/

    • Sean,

      Thanks for posting this. It is an excellent example of exactly what I am talking about. A naive reader might look at the prices listed and believe that is what it would cost to have one of these procedures. Hardly.

      Read the fine print:

      “A list of what is NOT included in the fee is as follows:

      Any diagnostic studies necessary prior to the surgery such as lab, MRI, X-rays, consultations with specialists to determine medical risk/management, physical therapy and rehabilitation.

      Any hardware or implants necessary for completion of the procedure (plates and screws, e.g. for orthopedic procedures). …

      Any overnight stay at our facility can be arranged on a case-by-case basis for an additional charge….

      Expenses or fees resulting from complications subsequent to the completion of the surgery and discharge from the facility are also not included.”

      And this is for a select set of relatively simple procedures that the surgery center finds it practical to provide. Those implants can cost thousands of dollars. The diagnostic procedures can cost thousands of dollars. The fee covers “uncomplicated follow-up care”. But patients with heart disease and cancer- common causes of adult death- need extensive and ongoing follow-up care, for the rest of their lives after surgery.

      An insurance company knows all this. It is not that they do not care about facility, surgeon and anesthesiologist fees (which is all that site listed). It is they know that the total cost of care can be many times these figures. An individual, finding a list of prices on a website, is likely to make the mistake you made, and assume they know what the care costs.

      Even if they posted all their prices, for every single thing they do, one would need to know how much of each line item was likely to be used in a given case to have even a guess at the total price. Patients don’t know this. So they don’t know what their care will cost.

      • And yet, it seems to be working.

        Look, I’m not saying it’s a perfect situation, but I’m continually amazed at the perspective that says forget about the fact that something is happening in the real world, it can’t work in theory so there’s no use considering it.

        • What is “happening in the real world” exactly that you think everyone is ignoring?

          • In the real world, an awful lot of people are directly paying cash, thousands or even tens of thousands of dollars, based on real prices (i.e. not ‘chargemaster’ prices), for healthcare services that they and their doctor have decided they need, all without much in the way of interference from insurance companies. In some cases they’re uninsured, in other cases they have high deductible insurance, and in others they have ‘good’ comprehensive insurance that won’t cover a particular surgery. I know one young lady who has ‘good’ insurance that won’t cover her bariatric surgery, so she’s going to India to get it.

            Some of the posters here seem to be under the impression that self-pay medicine, even for some relatively expensive treatments and services (let’s just call $5,000+ ‘relatively expensive,’ for sake of simplification), just isn’t possible. It obviously is, otherwise these things wouldn’t be happening.

            • Well, I certainly would not say it is impossible.

              I would say it is less common than your posts would lead people to believe.

              I would also say it is not going a good idea in the case of emergency care or in the case of medically necessary procedures.

        • By your reasoning anybody can afford a few thousand dollars worth of body work on their car, so why carry car insurance? Anybody can afford a few thousand dollars worth of repair to the siding of their home, so why carry home owners insurance?

          • Hmm, that’s not my reasoning at all, but thanks for trying.

            I’m not saying people shouldn’t have insurance. I’m suggesting that an awful lot of healthcare doesn’t need to be in the third-party payment system, and I’m also suggesting that it seems odd to assert that families can afford $15,000 a year in insurance premiums (either directly or with employer/government subsidies included) but somehow things totally fall apart the moment a family instead pay $5,000 for insurance that covers the truly catastrophic expenses, and they use the other $10,000 instead to directly pay for their care. Or that it’s utterly inconceivable that an insurer might decide that it’s easier for all involved to just say “we’ll give you $4,000 towards your hernia repair, go find someone who will do it and either pay or keep the difference.”

            • I have been amazed at how many folks really don’t know some basic facts…

              1. Lifetime health care costs average about $300,000 a person.
              2. About 80% of those costs happen after age 40 – $240,000 or so.


              3. MEDIAN lifetime costs are much lower – half of us will pay a LOT less than either number.
              4. These costs include the overhead burden of processing payments through third party payers.
              5. Significant discounts for cash are readily available already – we have been paying cash for several years and generally get 30-40% off – and have seen discounts as high as 60%.

              There are ways to “insure” against catastrophic outcomes – like the rattlesnake bite that are better solutions for most people – catastrophic care/long-term care rider on life insurance.


              Once we have Obamacare in place I am expecting a lot of new products to be developed and agressively marketed in the life insurance business to provide better alternatives to the exchange offerings.

    • LonelyLibertarian – Bingo. My blog, the Self-Pay Patient, is trying to provide information and commentary on exactly what you’re talking about, for example my post today is about the use of critical illness policies as a substitute for ‘comprehensive’ health insurance: http://theselfpaypatient.com/2013/09/18/critical-illness-insurance-as-a-substitute-for-comprehensive-health-insurance/

      If you have any specific things you think I should be reporting on or covering, please drop me a line at selfpaypatient [at] gmail.com (ditto for anyone else).

    • Mike (sorry for lack of a direct reply, apparently the strings only go so far): I suppose it depends on your definition of ‘common,’ but I’d certainly agree that it’s not widespread – maybe a good comparison is to homeschooling, which isn’t common either but it’s hardly a trivial number of people.

      And self-pay healthcare is obviously problematic when it comes to emergency care, fortunately that’s a relatively small slice of all healthcare expenses. As for medically necessary procedures, it seems to be working just fine in that market. Why do you think it wouldn’t?

    • It’s amazing how much uninformed and/or unclear opinion is shared here. I’ll attempt to add a bit of clarity:
      1) On cash-costs. You may not be aware that right now (and for a number of years) if you turn 65 it is no longer legal to pay cash for health care. Once you fall within Medicare age, it is considered insurance fraud (!) for a provider to accept payment other than through the Medicare system. Think about that the next time you push for medicare-for-all. I have personal experience with this.

      2) The following has been said above in bits and pieces but not altogether in one place: the problem with confidential health info and ACA is as follows:
      1) While EHR incentives were prior to ACA, ACA makes EHR mandatory beginning in 2015. All of your health information MUST be in the system by then.
      2) While sensitive questions will not be asked by all doctors, they WILL be asked (appropriately) by some doctors. And beginning in 2015 ACA requires that those answers be in EHR.
      3) A variety of scenarios require honest answers to those sensitive questions. Examples: life insurance medical exam, certain forms of employment, etc.
      4) The national EHR database is accessible by untrained, unvetted, uncertified, unaccountable “facilitators” hired to help people get into Obamacare now, and other things later. A number of agencies are already wangling for deep access for their own reasons (eg IRS for deductions, HHS for benefits, etc etc)
      5) Put 1-4 together and you get: confidential info, required to be in the national database, with little if any security and/or confidentiality controls, and a huge number of unvetted people with access.

      If you voted for this, I hope you are happy with the result. Rather than allowing the industry to develop this over time and work out the kinks, they are forcing this disaster on us. No choice. And they are guaranteeing the result they sought: kill the system that was working for the majority, install a train wreck, then propose a supposedly heavenly single-payer system.

      • Actually you can pay cash for healthcare as a Medicare patient, it’s just a huge hassle in many cases. Basically you just need to go to a cash-only doctor that doesn’t accept any Medicare (there are several thousand of these across the country). The problem is that most of these cash-only doctors are in primary care, while often the medical needs of the elderly involve more specialty care, making it a bigger challenge for a Medicare recipient to find an appropriate provider than a younger person needing mostly primary care.