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Why The Mandates Must Be Tied To The Medicare Buy-In Option

One of the more frustrating aspects of Village Wonk blogging on the health care issue is the disconnect between the political ramifications of imposing an individual mandate without offering those you are forcing to buy insurance an affordable option. In their mind, the solution is to write about increasing the subsidy levels. Of course, they know that when President Obama said the bill could not cost more than $900 billion, that foreclosed a realistic subsidy level (might as well say let's do single payer or Wyden-Bennett. Never going to happen.) Besides that, they ignored how this approach merely was more feeding of the beast known as the health insurance industry and served to undermine their other pillar of concern - cost controls.

I have criticized them for this for months and months. Now we have a new and important wrinkle - the Medicare buy-in. Some continue to have faith in the Exchange idea. I have long stated I do not. I do believe that a Medicare buy-in available to persons eligible for the Exchange (which would be everyone whom the individual mandate will force to buy insurance) would solve both the cost containment problem and the political problem of forcing people to buy insurance. Jon Cohn writes:

The original idea of a public insurance option was to create a government-run plan, like Medicare, into which anybody could enroll. But those ambitions fell as the legislative process moved forward and the political opposition stiffened. The public option variant Harry Reid put in the bill now before the Senate would be available only to people buying coverage through the new exchanges, lack the pricing power that gives government programs their greatest cost-saving potential, and be available only in states that chose not to withdraw from it.

[. . . A] [m]ore promising [compromise] is a proposal that would allow older workers (perhaps ages 55 to 64) buying coverage through the exchanges* to purchase Medicare rather than a private policy. These workers, in other words, could pay for what is literally a government-run plan. It just happens to be plan that's already in existence, rather than one a reform would create anew.

This is certainly something I agree with. As Cohn writes - "what's more like Medicare than Medicare itself?"

Here's a question - when do the individual mandates start? Should they not start at the same time as the Exchange? Cohn writes:

Since exchanges wouldn't begin operating until 2014, at least under the Senate bill, the option wouldn't be available until then. And that's a long time to wait, particularly given the target population. People between the ages of 55 and 64 have a notoriously hard time buying coverage on their own, since their age and higher incidence of disease makes them the sorts of high medical risks insurers don't want to cover.

The senators negotiating this deal understand this, according to senior staffers. And while no decisions have been made--indeed, this whole deal is in flux, with numerous moving pieces--the staffers say the senators are thinking about one more twist: Making Medicare available even before the exchanges start up, perhaps as early as 2011.

That's a great idea. But I also think that a Medicare buy-in option should start for everyone subject to an individual mandate (putting them in the Exchange) the moment the individual mandate is imposed.

Cohn worries about cost:

Making Medicare available before the exchanges are ready gets complicated, because the premiums will inevitably be more than many workers can afford. (The idea is to make the program pay for itself, rather than dipping into the pool of funds for retirees, so the money coming in has to cover the medical bills this relatively unhealthy group would generate.) As such, Senators are examining whether it's possible to offer discounted premiums for the first few years, and then charging higher premiums later on to make up for it. (At that point, subsidies from the exchanges would be available to offset the costs).

Not sure why this would be a problem - accelerate the taxes on the wealthy (either through Reid's increase in the Medicare tax for those making more than $200K or the House's surtax on incomes in excess of $500k).

One final thought. Because worries about North Dakota will no doubt become central to this debate (I'm not kidding, Kent Conrad is already whining) - I think we should be prepared to put the Opt Out on the Medicare Buy-In provision. If North Dakota wants out, let them out.

Speaking for me only

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  • Display: Sort:
    I totally agree that whatever buy-in (5.00 / 1) (#39)
    by Anne on Tue Dec 08, 2009 at 11:06:07 AM EST
    there is needs to begin concurrent with mandates, not run several years behind.  

    My question is, though, whether there is any reason why a Medicare buy-in for those 55-64 could not be open to anyone in that age group, not just anyone in that group that also qualifies for the exchange?  I mean, other than the obvious one - that it would threaten the industry too much if it works well (but I think it will threaten the industry anyway, which is why I don't think it's going to happen).

    One of the things I hear a lot is that it's expensive for employers to provide health coverage to an aging workforce because the premiums just keep getting higher and higher as risk increases; if everyone 55 to 64 were eligible for Medicare, it would likely not just reduce the cost to the employer in the case of those who are working and on the employers' health plan, but might also provide some job security for employees in that age group as well (yes, I know it's discriminatory to let older employees go because they are costing too much, but employers find ways).  And, it would be available whether or not these age-eligible people were working.

    Anne (none / 0) (#40)
    by jbindc on Tue Dec 08, 2009 at 11:08:40 AM EST
    You should run for Congress!

    Parent
    If the group (none / 0) (#1)
    by lilburro on Tue Dec 08, 2009 at 09:22:51 AM EST
    is relatively unhealthy, then allow younger people to enroll.  Der.  IIRC Obama originally wanted to mandate coverage for those under 25.

    He did (none / 0) (#2)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:24:20 AM EST
    Really (none / 0) (#3)
    by lilburro on Tue Dec 08, 2009 at 09:27:24 AM EST
    younger people should get something for being mandated to buy sh*t insurance.  I have spent 2 years paying for insurance and I used it once - to get a shot.  Which I could've easily paid for out of pocket anyway.  

    Are there any studies to your knowledge about who the mandate most effects?  Single people, families, race, age, etc.?

    Parent

    You think that's bad (5.00 / 2) (#4)
    by Steve M on Tue Dec 08, 2009 at 09:32:45 AM EST
    you should see my crappy life insurance.  Seriously, I've paid all these premiums and I've never even used it once!

    People keep telling me I don't understand what insurance means but I don't know why they say that.

    Parent

    Heh (none / 0) (#5)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:36:26 AM EST
    Buuut, you must admit health insurance is different.

    lilburro's argument is that it COULD BE a RATIONAL decision for a young person to NOT insure for health costs.

    It may be disadvantageous to the rest of us, but for the "invincibles," making them buy insurance could be a bad deal.

    Parent

    Yes (none / 0) (#6)
    by jbindc on Tue Dec 08, 2009 at 09:42:12 AM EST
    Until they (heaven forbid)walk out into the street and get hit by a bus, or slip on the ice and break their leg, or get appendicitis, etc.  then what happens?

    Parent
    That is part of the calculus (none / 0) (#10)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:52:09 AM EST
    Suppose they break their leg. Suppose they go to the hospital. Suppose the cost is $20,000.

    Suppose the chance of that happening in a five year period is 1%.

    Suppose further that health insurance premiums cost $6,000 a year.

    So you have in your scenario the following decision to make - pay $30,000 for insurance to cover (and I am calling this 100% coverage) a $20,000 cost that has a 1% chance of occurring.

    That one is a no brainer. You forego the insurance and put the 30,000 in the bank. then you can pay the 20,00 hospital bill and have the 10k plus interest left over.

    Obviously, there is more than that to the calculus, but that is the general idea.

    Parent

    One thing that you have not taken (5.00 / 1) (#23)
    by MO Blue on Tue Dec 08, 2009 at 10:05:42 AM EST
    into account is the probability that the money will be spent on other thing rather than putting it in the bank for possible health care emergencies.

    When a  young person or anyone else for that matter incurs large hospital and doctor bills and does not have the financial ability to pay for them the debt is written off. These write offs are calculated into the cost of services and everyone else who pays for these services picks up the tab in higher cost of services.

    Parent

    I was providing a philosophical argument (none / 0) (#25)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:07:04 AM EST
    Not a policy argument.

    My policy argument is pithily provided in the title of my post.

    Parent

    BTD, health insurance is no longer just insurance (none / 0) (#15)
    by andgarden on Tue Dec 08, 2009 at 09:56:20 AM EST
    It's about the piece of mind of being able to know that you can visit a doctor. It's still looking like there's an element to this discussion that you're missing.

    Parent
    Apparently not (5.00 / 1) (#16)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:57:36 AM EST
    for young people who decide not to have insurance.

    they seem to have "peace of mind" just fine.

    Parent

    Some are, yes (none / 0) (#21)
    by andgarden on Tue Dec 08, 2009 at 10:04:38 AM EST
    You think their parents are happy that they're walking around without insurance? Even supposing they are, they should still have coverage. Suppose a 20-year-old is diagnosed with cancer? Suppose they wait for treatment until it's advanced? As they die slowly, the state picks up the tab. (And that's even leaving aside the point that we do not want people to go without regular medical checkups).

    Parent
    Not against a mandate (5.00 / 1) (#24)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:06:14 AM EST
    Against a mandate that comes without an affordable decent insurance coverage option.

    the Exchange does not provide it.

    Hence the TITLE of my post.

    Parent

    Let's just nail this down, though (none / 0) (#27)
    by andgarden on Tue Dec 08, 2009 at 10:09:50 AM EST
    The compromise being discussed in the press leaves everyone under 55 at the mercy of the insurance companies, mandate and all. That's the "camel's nose" compromise that I don't think is close to worth it.

    But if the compromise is to open Medicare to everyone who's subject to the mandate (and that is everyone), then great.

    Parent

    Not sure that's true (none / 0) (#35)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:13:38 AM EST
    Let's see what Brown comes up with.

    I hope he proposes what I wrote in my title.

    Parent

    I guess my question then is (none / 0) (#26)
    by jbindc on Tue Dec 08, 2009 at 10:09:30 AM EST
    If young people forgo the insurance and something DOES happen - then what happens? Is the hospital going to be able to go after them for payment?  Is the government?  Or will it be like the status quo and the hospital will eat the costs? I assume this is without the mandates?

    Parent
    I assume that most 20 somethings (none / 0) (#29)
    by andgarden on Tue Dec 08, 2009 at 10:10:52 AM EST
    are effectively judgement proof.

    Parent
    Esp. (none / 0) (#7)
    by lilburro on Tue Dec 08, 2009 at 09:45:28 AM EST
    IMO for those who would fall under the guidelines of the exchange.  You may not be willing to purchase an individual insurance plan as a recent college graduate, for example.  Why bother if you figure in a few years you will have a job where the employer provides the coverage.  Young people not buying health insurance was one of the main sources of the mandate debate to begin with.  

    If you are a young person in the Exchange, I would think the mandate would sound like a very bad deal indeed.

    US News

    The number of young adults without health insurance rose again in 2006, so 38 percent of high school graduates and 34 percent of college graduates will spend some time uninsured in the year after graduation, a new report shows.


    Parent
    Why bother? (none / 0) (#9)
    by Steve M on Tue Dec 08, 2009 at 09:51:37 AM EST
    Because something might happen to you in those few years, obviously.  Look, I was a recent college graduate once upon a time myself.  You can't fool me into thinking that all of us were sitting around making wise, prudent, deeply-thought out, economically rational decisions.

    Parent
    We weren't (none / 0) (#11)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:52:47 AM EST
    BUT if we were, we might have foregone buying insurance.

    See my response to jb.

    Parent

    Except (none / 0) (#20)
    by Steve M on Tue Dec 08, 2009 at 10:03:59 AM EST
    that you need to add up a lot more risks than just breaking your leg, some of which carry a cost that is far too large to save up for.

    And of course none of these people are actually putting tens of thousands of dollars into a medical savings account, even though it might be the economically rational solution, which tells you something about how many of them are being economically rational.

    And of course something might happen to you in year one, before you have any money banked at all!

    Clearly any insurance policy has a price at which it's no longer worth purchasing.  That is a mathematical truth.  But it's also a red herring, given how bad people are at correctly valuing long-shot risks.  They don't have any idea one way or the other if a given policy is worth it; their thought process is limited to "I'll probably be okay, so no point in buying insurance."

    Parent

    All true (5.00 / 1) (#22)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:05:17 AM EST
    Just making a a philosophical point.

    My main point is that a mandate should be tied to an affordable and decent option.

    If you are going to make them have insurance, try to give them an option that is decent.

    Parent

    Sure (5.00 / 1) (#30)
    by Steve M on Tue Dec 08, 2009 at 10:12:01 AM EST
    I have said the same thing ever since I was a pro-mandate Hillbot in the primaries.  "Of COURSE you can't have a mandate without a public option," I naively insisted.  Frankly, even subsidized private insurance wasn't really in my thinking at that point and there's still something of a philosophical problem with it.

    Parent
    Well (none / 0) (#32)
    by lilburro on Tue Dec 08, 2009 at 10:12:26 AM EST
    it does not really matter why young people aren't buying insurance, just that they aren't.  Nearly 30% of people in their 20s (13.2 million) were uninsured in 2007.  CNN:

    The total number of uninsured that year was 47 million, which means "young invincibles" composed almost one-third of all the uninsured in the U.S.

    13.2 million is more than the amount covered in the House public plan according to the CBO.

    I am guessing a lot of the 13.2 million are going into the Exchange.

    We chose to "fix" this problem by mandating the purchase of insurance.  So young people certainly have a right to ask what they are getting for that.

    Parent

    Indeed (5.00 / 1) (#36)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:14:56 AM EST
    And therein lies the POLITICAL aspect of my policy argument presented pithily in my title.

    You know, I think I need to reread my post to see if I actually wrote anything.

    From the comments, I get the distinct impression I left it all blank.

    Parent

    I agree with what you are saying (5.00 / 1) (#37)
    by lilburro on Tue Dec 08, 2009 at 10:20:45 AM EST
    my point is that the Medicare buy-in being extended to young people is something you (and probably many others) don't think is going to happen now.  I think the "young people get what exactly?" angle reinforces your point.  Unfortunately people under 30 are not as well organized as other age groups.  No AARP for them.

    Parent
    Don't forget (none / 0) (#42)
    by Molly Pitcher on Tue Dec 08, 2009 at 11:31:27 AM EST
    that the under 30's are still getting married and having kids (maybe that should be with or without marriage).  In the long-ago days when Blue Cross admitted groups as small as 8 people, I joined my Dad's group. I was 23 and married.  Guess what?  We had a baby--hospital paid for--and the baby had Down's syndrome.

    That 'baby' had Blue Cross insurance coverage, eventually plus Medicaid, till she was shifted to Medicare when her dad died. (Handicapped kids are covered past the usual age of 23.)

    Making insurance affordable during the baby-making years might actually reduce the number of children who need CHIP.

    Parent

    Indeed. Also that age group is sexually active (none / 0) (#46)
    by DFLer on Tue Dec 08, 2009 at 05:24:02 PM EST
    and in need of birth control, other repro options, STD help. etc.

    Free clinics for the youths would be good

    Parent

    Sure (none / 0) (#8)
    by Steve M on Tue Dec 08, 2009 at 09:50:04 AM EST
    but it depends on a risk/reward analysis, the scope of coverage, etc., not whether you use it.  Of course you never know in advance whether you might be the unlucky one to get in an accident, develop a serious illness, etc.  Human beings are notoriously bad at evaluating risk in a rational way, particularly something like medical risk, and you see a lot of comments talking about "junk insurance" without any kind of analysis of whether it is junk.

    Let's say you get hit by a drunk driver and need lifesaving medical treatment.  If you don't have insurance to pay for it, who is going to bear the cost?  Seems like either the hospital or the government ends up having to eat whatever cost they can't recover from the patient.

    That's the rationale for the government saying "look, we don't want you to take a free ride and stick us with the costs if something happens to you."  There are plenty of low-cost, high-deductible catastrophic insurance policies that fit this paradigm nicely.

    Parent

    34%. (5.00 / 1) (#17)
    by lilburro on Tue Dec 08, 2009 at 10:00:50 AM EST
    I don't think college graduates are sitting around working on the calculus, I think they are thinking "I don't care, I will be fine."  And frequently they are.

    I understand the mandate.  I have health insurance.  But if I'm going to be forced to continuously pay for health insurance, I might as well have options outside of the insurance industry.  And government bargaining power.

    Perhaps young people saying "hey, wait a minute..." with regard to being incorporated in the health care "reform" will enable it to become more progressive.

    Parent

    Meh (none / 0) (#13)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:54:35 AM EST
    It's more of a money/low risk grab.

    I doubt the health care costs of uninsured young people is the big problem in health care.

    That's fine by me. I am a Common Good type of person.

    But the political ramifications can not be ignored.

    Parent

    If they are being forced to buy private (none / 0) (#12)
    by inclusiveheart on Tue Dec 08, 2009 at 09:54:02 AM EST
    insurance, then it really doesn't help with the government program for those aged 55 and over.  So I don't see any rational reason to force that group to buy health insurance from a private insurer - especially since it is clear that their contributions over time won't go into expanded and accesible coverage for others in the pool - their contributions are pure profit and will be filtered through the private insurers' system as such.

    The private insurance model for healthcare is a failed business model.  The more this debate goes on, the more obvious that becomes.  They want mandates, subsidies, exceptions to anti-trust laws, free reign to charge whatever they want, the ability to rate risk (which is more and more ridiculous given the fact that there are so many ways that people can get sick), the ability to avoid the sickest populations (I guarantee that the private insurers are saying "Yay get rid of the 55 to 64 demographic!") and this Congress is giving it all to them.

    I am more and more inclined to suggest that we go completely free market on healthcare - and that means that every single special status is stripped from these companies, that we can hire and fire them at will - hourly if we are so inclined - and that we as individuals can form our own groups and insure ourselves.  Then they'll go bankrupt and we'll get a government plan.  Okay, that might be pie in the sky on the last prediction, but at least they might not have as much money to lobby against us.

    Parent

    Hello? (none / 0) (#14)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:55:23 AM EST
    Medicare Buy-In.

    It's like you did not read my post.

    Parent

    No I read your post. (none / 0) (#18)
    by inclusiveheart on Tue Dec 08, 2009 at 10:02:15 AM EST
    And I read the other one you posted this morning.  And I have read a number of other articles about this new idea this morning.

    I think it is great that they are thinking about opening up Medicare to 55 and older, but like all the rest of these proposals not all 55 and older who will qualify.  Furthermore, if the mandates for people 54 and younger stay in, it is still just a big give away to private insurers; and political poison imo.  And finally, in my last paragraphs I was expressing in my free form contrarian way my total and utter frustration with this healthcare debate to date.  Sorry to annoy.

    Parent

    I dunno (none / 0) (#19)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:03:37 AM EST
    I like the  comments to address what I write.

    But fell free to express your frustration. Maybe in a free standing comment though.

    Parent

    re young people buying insurance (none / 0) (#33)
    by robotalk on Tue Dec 08, 2009 at 10:13:28 AM EST
    The problem here is the premium cost typically is related to the risk cost.  Duh.

    But that's not actually how it works.  Because hospital and doctors deem medicare payments to be insufficient, they actually charge non-medicare patients much more than their risk would reflect.  That might well worsen with a reduced age of medicare recipients who are relatively high risk/use.

    The two big issues in healthcare are, one (and somewhat pathetically) saving the (now) for profit health insurers and, two, cost containment.  No proposal adequately deals with these issues presently.

    Parent

    The Baucus bill (none / 0) (#44)
    by Socraticsilence on Tue Dec 08, 2009 at 05:02:34 PM EST
    required Insurance companies and/or state run plans offer "Young Invincibles" coverage for those 25 and under- its basically a bare bones plan that only covers catastrophic injury and is priced accordingly, I'm not sure if this is echoed in other plans.

    Parent
    Ok let's assume (none / 0) (#28)
    by jimakaPPJ on Tue Dec 08, 2009 at 10:10:10 AM EST
    a single payer system based on the Medicare Model for those that want it.

    What will happen to Medicare premiums for current members and will the new members have the same deduction and copays??

    At copays of 20% of Doctor bills and $800 per hospital stays, Medicare doesn't cover anyone 100%!

    Supplemental insurance to pick up the difference is running in the $180/month range and that doesn't cover dental and RX.

    We'll keep it the same (none / 0) (#31)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:12:13 AM EST
    by taxing rich folks like you Jim.

    Parent
    My richness is exceeded (none / 0) (#48)
    by jimakaPPJ on Tue Dec 08, 2009 at 06:09:31 PM EST
    only by my happiness last Saturday afternoon in Atlanta...

    Parent
    Is there copay assistance (none / 0) (#34)
    by Steve M on Tue Dec 08, 2009 at 10:13:35 AM EST
    for those who genuinely cannot afford it?  Is the supplemental insurance subsidized for those people or is it handled a different way?

    Parent
    The supplemental is private.. (none / 0) (#49)
    by jimakaPPJ on Tue Dec 08, 2009 at 06:12:18 PM EST
    United Healthcare, Blue Cross, Humana, Aetna is available....

    Medicaid is available for people who meet the Medicaid guide lines

    Parent

    Considering the fact that (none / 0) (#43)
    by Ga6thDem on Tue Dec 08, 2009 at 12:38:03 PM EST
    my premium is 700 a month and it the hospital copay is 5K, what are you whining about? When people compare that to the cost of private insurance it's a real deal even though it doesnt start with RX.

    Parent
    Sounds terrible (2.00 / 0) (#47)
    by jimakaPPJ on Tue Dec 08, 2009 at 06:08:10 PM EST
    Did you make a decision to put yourself on a career track that led you there or was it some minion of Bush's?

    And I reject your "whining" snark. I posted information only to ask a question.'

    Do you want government provided insurance and pay maybe $8000 or so in copays??

    Parent

    Well (5.00 / 0) (#51)
    by Ga6thDem on Tue Dec 08, 2009 at 07:06:16 PM EST
    considering the fact that Bush wrecked the economy he certainly has a share of the responsiblity of the economic problems that are around today. anyway, unless you work for a fortune 500, you dont get benefits anymore silly one. I'm a 1099 and my husband works for a small business that doesnt offer benefits. So you need to get a clue as to what's going on there with the economy. You can't just "choose" to get a job without insurance. You get the job you can get and deal with it.

    Parent
    well one thing that needs to be noted (none / 0) (#45)
    by Socraticsilence on Tue Dec 08, 2009 at 05:03:39 PM EST
    is that current Medicare recipients don't pay "premiums" they pay deductibles.

    Parent
    Wrong health care breath... (none / 0) (#50)
    by jimakaPPJ on Tue Dec 08, 2009 at 06:28:20 PM EST
    Medicare 2009 monthly premium's for individual returns are:

    < 86K - $96.40
    $85,001 - $107,000 = $134.90
    $107,001 - $160,000 = $192.90
    $160,001 - $213,000 = $250.50
    > 213k - $308.30

    Joint returns:

    <$170K - $96.40
    $170,001 - $214,000 = $134.90
    $214,001 - $320,000 = $192.70
    $320,001 - $426,000 = $250.50
    > $213K - $308.30

    Parent

    Much like the mandates should have been tied (none / 0) (#38)
    by ruffian on Tue Dec 08, 2009 at 10:59:55 AM EST
    to the availability of a Public Option. If the Medicare buy-in is supposed to be a reasonable replacement for the PO, then it stands to reason that it be available to those subject to the mandate.

    However I'm pretty sure the PO plans on the table did not let everyone buy in to them either. If the version of the PO that they are replacing is the one that only had a few million people eligible, I can see why they think a Medicare buy-in floor of age 55, and only if they can't afford anything else, seems reasonable.

    To me, as I've said before, every new idea with its imposed limitations just points out the futility of anything but single-payer. Anything else is just protecting the insurance companies from the free market.

    BTD, (none / 0) (#41)
    by cpinva on Tue Dec 08, 2009 at 11:25:04 AM EST
    your "risk" analysis is seriously flawed, even taking into account its skeletal nature. it assumes, with no basis for that assumption, that "20 somethings" only seek medical care for emergencies, such as the "1% probability broken leg", an assumption not borne out by reality.

    most people seeking medical care (other than regular checkups) do so for illness. only once, in 19 years, have we sought medical care for a broken bone, thank goodness. however, in that same period, the number of illness related visits is in the hundreds. i submit that is where the bulk of health costs arise from as well.

    so, your newly minted, uninsured "20 something" should be saving, not for the rare broken bone, but for the mundane illness. left untreated, many of these common (and treatable) illnesses can cause permanent damage, or even death.

    should you doubt me (and there's no reason you shouldn't), do this: go to the nearest hospital ER, or privately run emergency medical facility and do a quick survey. i'll bet money that the majority are there for illness, not major trauma.