ABCNews has an interesting article on a movement within doctors to forego insurance altogether:

It's a terrible indictment of the collapsing health care system," said Arthur Caplan, chairman of the medical ethics department at the University of Pennsylvania Medical School. "Insurance and managed care were supposed to streamline instead what they've done is add so much paperwork and bureaucracy they're driving some doctors out."

When O'Brien leaves the exam room, he writes a check for $50 and he's done no forms, no ID numbers, no copayments.

"This is traditional medicine. This is what America was like 30 years ago," said O'Brien, 55 and self-employed, who believes he has saved thousands of dollars by dropping his expensive insurance policy and paying cash. "It's a whole world of difference."

It's an interesting shift that has gone on where insurance companies have instead become health care providers. In yesteryear, health insurance was just that: Insurance against catastrophe. These days, however, insurance instead has their hand in every aspect of our health care. They pay for pharmaceuticals, doctor visits, routine tests, and so on. While this is ostensibly a good thing because it makes every day health expenses cost less for the average American, it has created boat-loads of paperwork and bureaucracy. Not only that, but we all pay for it in the end anyhow with the monthly payroll deductions or through lower wages because our employers are having to pay more.

For the most part, I would prefer a more insurance-based health insurance system. I'd much rather pay the insurance company less on a monthly basis and pay for more of my routine checkups, tests, and so on. That's similar to the arrangement that I have with Fortis at the moment until I can get a job with a more traditional plan. I would honestly consider sticking to Fortis except that if disaster ever does strike, after paying for it you can't get insurance through them again.

That brings to light one of the two problems with the "old way." Without some sort of regulation those that have the most health problems would be least capable of getting coverage. Under the current system (as I understand it) anyone that's employed cannot be denied health insurance indefinitely due to past ailments. The insurance companies can forego coverage for pre-existing conditions for up to a year if insurance coverage has not been constant and companies can decline paying for health insurance up to 90-120 days (maybe more) for new employees, but those with stable employment will get coverage at some point. Without some reform, that would not happen for companies like Fortis.

The second issue is those that require expensive medications on a regular basis. What immediately due to my experiences comes to mind for that are those suffering from depression or some other mental illness. I've never taken such medications, but a large number of people around me have and they need that to function. These medications can cost up to hundreds of dollars a month and it is certainly in society's best interest that they be covered.

On the other hand, medication is expensive to produce and an often simply forestall the inevitable when it comes to the elderly and terminally ill. A lot of people gripe about the big pharm companies charging and arm and a leg for medications, but the simple fact of the matter is that there are more of those medications available every day. But for every new medication that helps with this problem and that, it's going to cost money. From a practical standpoint, the government and insurance companies can run themselves completely into the ground by paying for everything for everyone. Many of the left (and too many in the center) want medical care (including medication) to be a right. If they succeed in this regard, it can be prohibitively expensive if we can't draw the line somewhere.

Additionally there is the matter of false positives. If doctor visits don't cost anything (or cost $10), a lot of people will go to the doctor at the first sign of a problem, whether they need to or not. If it doesn't cost the user anything, the user will not show any discretion before using the services available to them. This has been demonstrated time and time again with guaranteed emergency care. Since people cannot be turned away in the emergency room, then non-emergencies become emergencies very quickly. As it stands, hospitals are able to bill emergency room care recipients, but those bills can be hard to collect.

At the same time, I have difficulty advocating turning emergencies away at the door. Similarly, I am uncomfortable with people dying simply because they cannot afford simple treatments. On top of that, people will less income may forego visiting the doctors office (and will certainly forego regular checkups) as minor illnesses become major.

To the left, the answer is universal health care. In this vein, it's better to waste money on unnecessary visits and medications if it prevents problems down the road. Perhaps that's the case, but then doctors - the most educated and trained profession in the country - will become little more than public servants.

Speaking of which, Michael Williams has a disturbing post on that very subject. Due to high malpractice insurance premiums, neurosurgeons in a Florida county stopped accepting emergency patients and a woman died of a stroke while they tried to call someone out of the country to take care of her:

"If you have a stroke in this part of the country then you're in deep trouble because the doctors won't see you," Masterson said.

Some neurosurgeons (search) aren't disputing his claim, saying they can't afford malpractice insurance and are afraid of being wiped out by lawsuits, so they reduce their risks by refusing emergency patients.

"It makes me feel very bad that I can't take care of a lot of patients... That I have to send them on and I can't take care of them - can't accept that risk," said Dr. Jacques Farkas, a neurosurgeon in Palm Beach County (search).

Last month in Tallahassee, Fla., physicians blamed frivolous lawsuits for sky-high medical insurance and pushed for caps on malpractice attorney fees.

But some trial lawyers say there is no malpractice crisis and that patients are dying because doctors are playing the blame game instead of doing their job.

"I think its criminal," said trial attorney Marvin Kurzban. "I think its dereliction of duty. I think that's malpractice also."

As Michael and commenters point out, this creates a damned-either-way scenario where doctors are succeptable to lawsuits whether they do anything or not. This, in turn, makes them little more than civil servants.

Doctors-as-civil-servants is the norm in Canada. Whether or not it's working up there is subject to debate:

Quality is subjective and can only be evaluated through consumer choices, but the government won't let consumers make choices and vote with their feet if they are not satisfied. Anecdotal evidence of questionable quality is everywhere. In a recent piece in Montreal's Gazette, a Canadian related her own experience, and contrasted the "kindness, discretion and professionalism" of staff in U.S. hospitals, with the frequent rudeness of unionized personnel in the Canadian system.

Long waiting lines are a fixture of the system. The Fraser Institute, a Vancouver think tank, has calculated that in 2003, the average waiting time from referral by a general practitioner to actual treatment was more than four months. Waiting times vary among specialties (and, less wildly, among provinces), but remain high even for critical diseases: The shortest median wait is 6.1 weeks for oncology treatment; excluding radiation, which is longer. Extreme cases include more than a year's median wait for neurosurgery in New Brunswick. The median wait for an MRI is three months. Since 1993, waiting times have increased by 90%.

Waiting lines impose a real cost, which is approximated by what individuals would be willing to pay to avoid them. Waiting costs include health risk, lost time (especially for individuals whose time is most valuable), pain and anguish. Socialist systems are notoriously oblivious to anguish, discomfort, humiliation and other subjective factors which bureaucrats cannot measure or don't value the same way as the patient does.

That's from a Wall Street Journal article cited by Tom Kirkendal, where he discusses the partial solution of Health Savings Accounts:

HSAs allow individuals and their employers to make deposits each year equal to their health insurance deductible (there is currently a limit on the size of the deductible and a supplemental insurance policy is required to cover catastrophic illness or injury expense in excess of the amounts deposited in the HSA). The funds in the HSA grow tax free and the funds may be used to pay such things as health care expenses that would not otherwise be covered by third party insurance, insurance premiums while the owner of the account is changing jobs, and health expenses during retirement.

However, the new law is not perfect. For example, as noted above, the maximum amount that can be deposited into an HSA in any year is currently somewhat limited. Consequently, the combined cost of depositing funds in the HSA and paying for the supplemental insurance that is required can turn out to be more expensive than simply buying a third party policy with a relatively high deductible.

Moreover, products such as HSAs are only part of the solution to the problems in America’s health care finance system. From my vantage point, some sort of nationalized insurance or federally-backed private insurance is still going to be necessary for people who simply cannot afford to fund HSAs or buy private insurance, and for people with severe medical problems who cannot afford the costs attendant to those problems. In regard to these groups, the tough issue is how do you ration the health care? Or, stated another way, there must eventually be a political consensus on the limitations of such federally-insured health care. Otherwise, we simply have created another federal program that balloons into yet another governmental financial debacle.

Tom also links to and discusses another WSJ article on pharmaceuticals, which ties right back in to what we expect - and should expect - from insurance companies and how the current system health-care-provider-instead-of-insurance system may be presently failing us:

America's real problem is that drugs have been roped into the same perverse incentives that govern most health care spending. Consumers don't weigh cost vs. benefit; drug companies focus their development efforts on drugs aimed at large populations of price-insensitive, insured patients. At the same time, consumers who don't have drug insurance and pay out of their own pockets scream bloody murder because drugs seem like a violation of a natural order in which medical care is increasingly perceived as a costless entitlement.

Think we exaggerate? Everybody noticed when HCA, the big hospital chain, earlier this month put aside $700 million to cover the bad debts of uninsured patients, who are typically good for only seven cents on the dollar. Little noticed was the fact the company also has to cover the bad debts of insured patients, who routinely skip out on their co-payments and deductibles. Nowadays these people are good for only 45 cents on the dollar on average.

Medical bills seem to have become optional to Americans when deciding which envelopes to toss in the trash unopened at the end of the month. "Hospitals are ninth" on the payment list, HCA's Chief Jack Bovender told Reuters in February, well behind mortgages, car payments and cable-TV bills. "The only thing people pay worse is the student loan program."