Thu
Jun 22 2017
05:07 pm
CNN comparing the three ...
Comparing the Senate health care bill to Obamacare and the House proposal
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Buy on same exchange as members of congress use
Sen. McCaskill proposes if people don't have an insurance company in their county let them buy on same exchange with their subsidies that members of Congress use.
About 4:20 mark
McCaskill: GOP used the ACA as a 'political 2x4'
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Sen. Bernie Sanders was interviewed on the GOP Senate healthcare plan on CNN earlier tonight. He called it "barbaric" and said it was the single most disgraceful bill he'd seen in his 30 plus years in office.
He will attend speaking events in three states this coming weekend (Ohio, Pennsylvania, and West Virginia) to urge its defeat and to promote his own Medicare for All alternative.
CHART: Who Wins, Who Loses With Senate Health Care Bill
from NPR.org ...
CHART: Who Wins, Who Loses With Senate Health Care Bill
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Cable news networks are reporting that as of today, five Repub Senators have announced they won't vote for the bill, making it unable to pass (in its present form) with just 47 possible votes.
Over at his FiveThirtyEight blog, though, Nate Silver pegs defectors at nine, as follows:
Silver goes on to mull what's helpful and what's harmful to the Senate bill's passage, observing that there seems to be a bit more to harm passage than to help it, at least relative to the difficulty House Repubs had in passing their version. He does conclude, though, that neither its supporters nor its detractors should feel confident just yet.
Meanwhile, you may or may not be aware that Rep. John Conyers' Medicare for All bill in the House (H.R.676) now has a record breaking 113 co-sponsors.
(If Sen. Bernie Sanders has yet introduced his own Medicare for All bill in the Senate, I haven't been able to spot it.)
The draft Senate bill, called
The draft Senate bill, called the Better Care Reconciliation Act,
Better care? Ha, ha, ha, ....
Medicaid. Instead of open-ended payments, the federal government would give states a maximum payment for nearly every individual enrolled in the program. The Senate version of the bill would increase that allotment every year by a formula that is expected to grow substantially more slowly than the average increase in medical costs.
...
States would continue to receive extra funding for Obamacare’s expansion of Medicaid to more poor adults, but only temporarily.
...
High-income earners would get substantial tax cuts on payroll and investment income. Subsidies for those low-income Americans who buy their own insurance would decline compared with current law. Low-income Americans who currently buy their own insurance would also lose federal help in paying their deductibles and co-payments.
Etc., etc. ...
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(in reply to bizgrrl)
Sure looks to me like Repubs don't have a very clear understanding of where those "entitlement programs" are "growing."
Required reading for Mitch McConnell: The Absurd Amount of Entitlements That Go to Rich People.
And they live longer to collect them longer, too.
It's mostly Obamacare without the taxes to pay for it.
Possibly a worse fiscal disaster than even Obamacare.
And it accepts the premise that the federal government should & can pay people's insurance bills, which is simply always going to fail.
Everyone's fixated on a million shell games, all trying to get someone else to pay their over-priced care bills. But that doesn't fix over-priced care, dumping money on over-priced services feeds it.
Very annoying.
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(in reply to traveler)
Personally, I'm a big supporter of single-payer health care--but you're certainly right that it can't succeed (even if/when enacted) until the U. S. gets a grip on its "overpriced care bills" more generally.
Per this (three year-old) Consumer Report article, our health care costs per capita are the highest in the world, running about double those of other developed countries.
Do note this text in the article, though:
So while it's true that there are multiple reasons our health care costs here are so high, a single governmental insurer as in the so-called "Medicare for All" proposal would appear to be a help in lowering those costs the insurer (and we) would need to pay.
I think prices might steady
(in reply to Tamara Shepherd)
I think prices might steady or even lower once everyone is covered. In the past hospitals and some other providers charged more for having to write-off care given to non-paying patients.
Private insurance company prices are also low as compared to fee for service prices (no insurance), unless the provider discounts the prices because you are paying up front out of pocket (no insurance).
*
(in reply to bizgrrl)
I don't see private for-profit insurers ever covering everyone, unless it were to become required by law.
Even then, we'd still have this issue of private for-profit insurers jockeying to become The Biggest Insurer so as to negotiate lower prices from the private for-profit providers--lower prices for the insurance companies themselves, that is, which savings might or might not trickle down to their policy holders. Remember, we'd still have both the providers' and the insurance companies' profit motives at work in such a scenario.
And that's the root problem with our health care (and health insurance) system: A system that allows individuals to profit from the misfortune of others is fundamentally flawed, no matter how we tweak it.
Think private for-profit prisons and their complete lack of any impetus to lower crime.
Some fundamental societal functions simply shouldn't be in the hands of "business owners" and health care is one of them.
I agree with your premise
(in reply to Tamara Shepherd)
I agree with your premise that health care is important, which is what drives me to the opposite conclusion.
To wit, the last thing I'd want would be for healthcare to be in the hands of people who can run it so badly they'd lose money hand over fist, and do so without the slightest care.
I much prefer someone who wakes up each morning trying to innovate new and better ways, and yes, even with the hope of being rewarded in their own lives, for bringing society that new, good thing.
Profits are a very, very positive societal good. They spur people to improve and streamline everything they do, making whatever they make or do better, more affordable, and more accessible to more people.
That's a something to be encouraged at every chance.
What we don't want is this: people making profits unfairly, such as dishonestly, by theft, or insurers or hospitals making a mint because the government gave them an advantage over other people. That's destructive.
As long as someone is profiting by offering a better product or value--delivering something people want (and are willing to pay their own money for)--without unfairly taking opportunity from anyone else, that's a very good, healthy thing.
The cost of uncompensated
(in reply to bizgrrl)
The cost of uncompensated care is real, but not solved by simply putting those people on subsidized care. The latter just makes unpaid care the default setting, with the bill picked up by the taxpayers.
Also, the cost of uncompensated care does come close to explaining why we pay so much. That's maybe 10%?--not why our prices are twice what they should be. It's not like half the people in America don't pay.
I find that most doctors knock off 1/3rd or 1/2 for cash payments. Cash saves them a lot of hassle, and they greatly appreciate it.
Universal Medicaid deserves a
(in reply to Tamara Shepherd)
Universal Medicaid deserves a separate reply, after some sleep.
Cost is our principal problem. If prices came down by half--and I'm confident they could--most people would be able afford their own care. Many fewer would need our help, and helping them would be easier for society to do.
Lowering cost is the Holy Grail of health care planners, to where, in his lectures, Jonathan Gruber said no one knows how (except rationing), so he just threw a bunch of wild ideas into Obamacare to see which of them would stick. The "spaghetti" approach. None did.
But the current approach--this dismal competition of everyone trying to make everyone else pay their bills, either with insurance or the government--doesn't fix that cost problem. The third-party payer phenomenon drives it, reinforces it, feeds it.
Your Consumer Reports link accidentally hits the root:
That's it--people don't consider cost precisely because they all have insurance. Once they've paid their premiums, the incremental (i.e., added) cost of using a doctor is fairly small. Accordingly, people are likely to do it, and to not care about the cost. And if the consumer doesn't care about cost, neither do the suppliers.
And that's our problem. That's why costs have risen out of control.
We can fix it, fairly easily, I think. Once consumers start to shop for value, providers are compelled to try and provide it. And, providers are the only ones, ultimately, in a position to lower costs and provide care more efficiently.
For example, I wouldn't dream of trying to tell Ford how to make better cars more efficiently. They have all sorts of expertise--welding, materials, casting, machining, etc.--that I'll never have. But I don't need to to force Ford to improve their products and value. If people start buying Hondas instead of Fords, Ford will examine and re-examine every aspect of their operation under a microscope to try and make every bit of it better. And then they'll go back and do it again. And again.
That's what we want: hospitals, and drug companies, and doctors' offices waking up every day dreaming up new ways to cut costs, paperwork, hassles, delays, and make their operations better. We want them highly motivated, doing it to make more money, stay in business, and/or to keep their customers. They're the ones who can streamline better than anyone. Presently, they aren't.
We need to spur them. Ask your doctor "How much will that cost? How much is that drug? Is there another, less expensive option?"
Until we get the people who practice medicine motivated to improve its delivery, until prices are open and honest, costs will continue to rise.
Subsidies to hide the costs just fuel the cost-inflation fire. And trying to get other people to pay our bills is mere gamesmanship--that isn't going to fix it either.
health care is not a car
(in reply to traveler)
I don't want health care provided by people whose sole goal is to profit as much as possible from whether or not I'm healthy. You are arguing that the best doctors and scientists and pharmacists and etc. are the ones most profit driven, and I'd counter with the idea that the best of all of us are those of us trying to deliver the best we can. I want the doctor that wants me healthy and well, not the one who is constantly asking how I'm paying. I want to wake up every day knowing that the people in charge of health care are motivated to find the best way to keep all of us healthy and well. I don't want them worried about customers at all. I want them worried about how we're doing and how we're feeling. And I don't want it for free. I want us all to pay a fair amount of tax as a percentage of our income into a system that provides the exact same level of quality care because we can and because we care about each other and because every single person within the borders of our country is important and valuable and deserving of our best regardless of income or cash on the barrel head.
Who said it was their "sole
(in reply to schull)
Who said it was their "sole goal"? Regardless of their personal motivations, profit is a very sensitive feedback mechanism that tells a group of people how efficiently they're providing you your care. It keeps them from getting very, very sloppy. And in my travels, most of them are both caring, and very, very sloppy when it comes to wasting time and money.
If they can save some time wasted in one place, and have more to spend seeing patients, that's a good thing, and it doesn't hurt for them to get a little reward for it. Why begrudge them that?
But if you want people who actually care about you, somehow "Congress" and a bunch of zombie-like federal bureaucrats aren't the first thing that pop into my mind.
profit is a very sensitive
(in reply to traveler)
profit is a very sensitive feedback mechanism that tells a group of people how efficiently they're providing you your care
By that metric, insurance companies would maximize profit ("surplus" for "non-profits") by collecting premiums and denying all claims. Unfortunately (for them), government regulations prohibit that. ACA strengthened those consumer protections. Insurance companies would like to move the needle back in their direction. That's what this is all about.
Bonus question: if "free market" (industrialized) medicine is so great, why does the US have significantly higher per capita costs than every other country, most of which have some variation of single-payer or "socialized" health care? Also, why do our outcomes rank far lower than most other developed nations even though our spending is the highest? Explain the efficiency of that.
"traveler's" arguments are
(in reply to R. Neal)
"traveler's" arguments are pretty much all based on hoping you don't notice half of every equation being ignored. He claims consumers don't consider healthcare costs because they have insurance and thus don't have to care. This is only partly true. Consumers also spend their own money regardless of costs, because they desperately want to stay healthy or alive. That's why so many personal bankruptcies happen due to healthcare costs. He says profit is an effective motive, but then goes on painting his utopia where healthcare providers are laser-focused on cutting costs to beat the competition. This ignores the much more lucrative strategy of figuring out how to avoid competition and get consumers to buy more stuff and pay higher prices. That's why you can't let children watch the evening newscasts any more. Besides, a business that's waking up every day trying to figure out how to cut costs and lower prices to beat the competition is a business in a death spiral. Successfully raising prices is where the profit motive leads, and people's desire to live makes that a very lucrative strategy indeed. Then he references faceless government bureaucrats, while ignoring the faceless insurance and private healthcare bureaucrats who have already established their preference for profit over good and humane patient care. At least the government bureaucrats are supposed to have the interests of the voting consumers in mind.
If you assume your fellow
(in reply to Somebody)
If you assume your fellow Americans are children, unable and can't be trusted to decide for themselves, then it makes sense that you'd want to impose your decisions on them. But that's not a free society.
"At least the government bureaucrats are supposed to have the interests of the voting consumers in mind."
Why? Why would a government drone, secure in their job and generous pension and double the private-sector's wages, regardless of how well their job gets done, have any reason to care about you at all?
Government bureaucrats are
(in reply to traveler)
Government bureaucrats are actually human beings. They are your neighbors and family members. They are not drones. They also are not motivated by extracting profit from sick patients. They work for elected officials who are at least theoretically accountable to the public.
On the other hand, bureaucrats at private, for-profit companies are accountable to shareholders for maximizing profit. They are also human beings, neighbors and family members, but their jobs are dependent on generating profit for the company and its shareholders. As I've repeatedly explained to you, patients are highly motivated to spend whatever it takes for health or life itself. There is little to to motivate private bureaucrats to reach a rationally negotiated, reasonable supply/demand price point. Healthcare demand is inelastic. When one side has all the power, there is no negotiation.
The development of medical technology and the development of private and later public insurance are causally related. Private, public and public single-payer systems were developed specifically because the free market is unresponsive to the healthcare needs of the entire public.
The only way your ideas work is if you believe that human lives are only worth whatever wealth each individual can accumulate. I don't believe that my fellow Americans are 'children,' but it would seem you believe they are ledger sheets, worth no more than whatever it says on the bottom line.
Do you think private
(in reply to Somebody)
Do you think private employment turns our neighbors--caring people--into amoral monsters? I certainly don't find that.
I'm also somewhat flummoxed by the notion that "the free market is unresponsive to the healthcare needs of the entire public." Even as crippled and unfree as ours is (from meddlers, changing the incentives), nothing has served the needs of the public more.
America is fountain of innovation the rest of the world depends on. We pay the development costs of the world's drugs, while Europe (and most every other place) rides mostly free.
So, I simply don't see that bureaucrats are uniquely virtuous, or that people have to be commanded with respect to health care.
"As I've repeatedly explained to you, patients are highly motivated to spend whatever it takes for health or life itself. There is little to to motivate private bureaucrats to reach a rationally negotiated, reasonable supply/demand price point. Healthcare demand is inelastic. When one side has all the power, there is no negotiation."
You're assuming that patients are always desperate and always willing to pay infinite amounts. Those assumptions are simply false. You could make the same argument about food and farmers having us all over a barrel, and you'd be equally mistaken.
I personally shop for value virtually every time I see a doctor, and I'm careful to make sure they know I'm including their prices and the price of things in my decisions.
Very little of our care is that urgent, so this drivel we hear about "you can't negotiate when you're in the ambulance" is pablum. You don't have to. If you press them on other things, they improve in ways that benefit the entire delivery system.
"America is fountain of
(in reply to traveler)
"America is fountain of innovation the rest of the world depends on. We pay the development costs of the world's drugs, while Europe (and most every other place) rides mostly free."
There is so much that's incorrect and glossed over in your pronouncements. First, a large portion of medical and pharmacological research is funded by the government (though somehow, drug companies get the patents and the profits). Government funding tends to go toward the basic science needed for breakthroughs, and for research on things like AIDS and cancer. Private companies tend to focus more on chasing profit, funding clinical trials for the stuff that will make the most money, after all the basic science has been done, and all those drugs you see advertised on TV that tend to be focused more on lifestyle, rather than saving lives.
Second, a recent report in the Journal of the American Medical Association indicates that you're flat-out wrong about the rest of the world is getting a free ride, that funding for US-based has been on a steady decline (save for a temporary bump from Obama's stimulus package a few years ago), and that Europe, Asia and the rest of the world are positioned to take the lead in the near future if trends continue.
"You're assuming that patients are always desperate and always willing to pay infinite amounts."
No I'm not, but for the expensive, life-and death stuff, they sure as heck are. People will use coupons and buy generic for a bottle of ibuprofen. They will default to proximity and real or perceived expertise when their life depends on it.
I believe Medicare has the
(in reply to R. Neal)
I believe Medicare has the highest denial rate, or it least it held that honor within the past few years.
Kellogs could, you'd argue, raise their profits by selling you an empty box with no cornflakes in it. But you wouldn't buy it, would you?
And yet there's no law stopping them from offering an empty box if they wanted to, is there?
Side note: I don't understand all this "victim" psychology, as if we're all powerless infants at the behest of various boogeyman villains (e.g., insurance companies). If you don't like cornflakes, don't buy 'em!
___
if "free market" (industrialized) medicine is so great, why does the US have significantly higher per capita costs than every other country, most of which have some variation of single-payer or "socialized" health care?
We don't have a free market in medicine, that's absurd. You yourself have admitted you don't know the prices of what you're buying, and accept it when the doctors tell you that they don't know either! That's not a free market! You can't have a free market unless people choose based on value. How are they supposed to do that if they don't know the prices?!
"Also, why do our outcomes rank far lower than most other developed nations"
That's mostly not true--we have excellent outcomes. Try comparing our cancer survival rates to Europe's and you'll be glad you live here.
Most of those "rankings"-with-an-agenda give heavy weight to non-medical criteria such as "fairness" (even if equally bad) and "universality." Isolate the "outcomes" portion, and we're tops.
But we are fatter and more sedentary, and suffer the diseases that flow from it.
You type a lot of words and
(in reply to traveler)
You type a lot of words and talking points and reject a lot of analysis.
So, what's your solution? In a nutshell, how should health care delivery work in America?
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(in reply to R. Neal)
Given that Traveler dismisses any concern for "universality" of coverage as a "non-medical" issue, I think we know his/her solution.
That would be "personal responsibility," as in "I got mine, you get yours" and to hell with the ability to pay principle that guides healthcare delivery in the balance of the developed world.
"Universality of coverage"
(in reply to Tamara Shepherd)
"Universality of coverage" has nothing to do with "medical outcomes"--those are two different concepts.
I was explaining that the claim that "America has poor medical outcomes" usually involves misconstruing certain international rankings to suggest that we have poor outcomes. We don't, and the rankings don't say that we do.
WHO (The World Health Org), I think it was, ranked us as 36th, or 38th. But it would be simply preposterous to anyone who looks at the actual published data to imagine that the United States ranks 38th in medical outcomes. We do not.
Here it is:
(link...)
The error arises because those international rankings give surprisingly little weight to medical outcomes, and heavy weight to things that have nothing to do with medical outcomes.
"Medical outcomes" means "your chances of being cured in if you get sick." "Universality" is, essentially, "what portion of the population is covered by national socialized medicine?" Universality is poor consolation if you die from living in a country with universal coverage, but lousy outcomes.
Here's another ranking that puts us at the bottom of 17 nations, but if you examine the reasons, they're virtually all cultural / lifestyle, and NOT from lack of medical attention or quality:
(link...)
We have slightly shorter life expectancies, but for a variety of reasons, mostly from being fat and sedentary and cultural reasons (violence, car accidents, teen pregnancies). People naively presume that medical care can fix anything. It can't. If you're alcoholic and burn out your liver, there's only so much doctors can do.
But if you're sick, and go to a doctor, your chances of surviving and recovering in the United States are the best in the world for most conditions, and close to the best for most everything else.
Reject analysis? I'm
(in reply to R. Neal)
Reject analysis? I'm disputing superficially attractive "solutions," such as assuming a central authority at Medicare could just magically publish a current list of prices for every locality that work simultaneously across the country, in New York city and rural Idaho and everywhere in-between. And incorrect notions such as that we have poor medical outcomes (when we don't).
But, to answer your question, I think we should pay whoever's caring for us directly for our care, so that they work for us, and also eliminating *all* the middlemen.
To guard against disaster, buy catastrophic insurance. It will be very cheap, as it was even fairly recently.
Even though this cuts the cost about forty percent, there will still be some people who cannot afford even this. So we help them.
But it's important to look at why people can't afford care. If they're infirm or disabled, we care for them. Preferably at the state or local level, bringing the matter as close to the community as possible, but we care for them.
If their problem is simply being poor, then medical insurance is not solving their root problem. Their real problem is needing a better income, a better job, right? And if there's something we can do as a society that facilitates that, we do it. (For one, there are many barriers we've erected that could be removed.)
I'd like to get people to agree that medical care costs too much, and that if we, as consumers, simply pressed providers on price--which is not happening now--that we could have a large effect, and lower the prices for everyone.
That costs us nothing, requires no act of Congress, and takes no one's live, liberty, or property. And it's something we can all do right now.
That doesn't solve every single problem, but it goes a long way toward solving the worst problem: cost. If care cost less, more people could afford their own. Lowering the price tag makes the remaining problems smaller, and easier to solve. Fewer people would need help, and helping each of them would be easier for us to afford, too.
I'd want decisions and finances done as close to the communities as possible, because that's more responsive, humane, and simply works better than some eggheads in far away places.
And I would suggest that big changes should be taken in small steps, with time in-between to see if we've made a mistake so that we can back up and change course when needed.
I think we should pay
(in reply to traveler)
I think we should pay whoever's caring for us directly for our care, so that they work for us, and also eliminating *all* the middlemen.
To guard against disaster, buy catastrophic insurance. It will be very cheap, as it was even fairly recently.
That's essentially what we have now, if you consider high deductibles and co-pays.
Except for the middlemen. Personally, I'd rather have a government middleman with no profit motive.
Anyway, it's hard to discuss all this with someone who considers insurance stealing from your neighbor.
That's essentially what we
(in reply to R. Neal)
That's essentially what we have now, if you consider high deductibles and co-pays.
No!!! That's middlemen, busy-bodies, loads of mind-numbing time-wasting rules, bureaucrats and procedures, PLUS deductibles and co-pays.
And most critically, you haven't eliminated the third-party-payer problem--you still have someone else paying most of the bill.
Your description preserves the system of perverse incentives and inefficiencies that make our care so expensive.
Personally, I'd rather have a government middleman with no profit motive.
I'd much rather have someone with a vested interest, than a remote government overseer who doesn't care and with no stake in the outcome. I've been dealing indirectly with the latter all month, a fate I'd wish on no one.
They're degrading, putting the patient at risk with their delays, and making a cancer treatment ordeal fifty percent more dangerous, twice as expensive, and five times as horrifying as it should be.
Anyway, it's hard to discuss all this with someone who considers insurance stealing from your neighbor.
Of course insurance isn't stealing from you neighbor. But if you break into her bank account and use the money to pay your premiums, you'd be prosecuted, right?
Having the federal government do it for you under color of law doesn't change the essential nature or moral value.
You have clearly given this a
(in reply to traveler)
You have clearly given this a lot of thought.
I spent six of the last seven
(in reply to R. Neal)
I spent six of the last seven year researching facts, figures, and policy of it almost full-time, unpaid. Because I think it's that important. I've spoken to groups, on-air, nationally, and in Congress. And it's because of that effort I'm so sure it's something we can solve, in a way that helps everyone.
If prices fall, if we spur medicine to re-examine itself and the experts practicing it start improving it from within, everyone wins.
By simple estimates of how much time is wasted and needless expenses, I estimate medical care could cost half. Should cost half. Some doctors (who are living it) tell me it could cost 1/3rd.
But we need to be good stewards. Even when we have insurance, we have to ask our doctors how much things cost--not just our portion, the WHOLE cost--and insist on answers. Policy-wise, we need to listen to them if they tell us electronic medical records have them spending ten hours a week on a tablet instead of seeing patients.
Try it. You'll be amazed--most of them don't have any idea. And by asking, you'll force them to learn. Oblivious, they spend huge amounts for no medical benefit. We can change that, just by asking.
Hospitals are *awful.* They consider their prices trade secrets. How absurd--imagine a grocery store--with no price-tags--that refuses to tell you what things cost! That should not be.
I ask all the time. They
(in reply to traveler)
I ask all the time. They don't know. The reason is that prices are set by insurance companies (or Medicare or Medicaid).
For insurance companies, nobody knows what the cost will be until a claim is submitted. The price is different depending on the insurance company, their deal with the provider, the network, etc.
Then there's the price for uninsured. Sometimes it's lower, sometimes it's significantly higher.
With Medicare, it's simple. There's a published schedule of fees and that's what they pay providers. A single-payer system like this is much simpler, far more transparent, and fair. I don't understand why that's so difficult for people to comprehend.
That's nonsensical, right?"I
(in reply to R. Neal)
That's nonsensical, right?
"I ask all the time. They don't know. The reason is that prices are set by insurance companies (or Medicare or Medicaid)."
You're settling for an absurdity--how can doctors not know their own prices? But it's true, they don't. We need to change *that.*
"With Medicare, it's simple. There's a published schedule of fees and that's what they pay providers."
Medicare publishing a list of what it will *pay* is not the same as providers publishing a list of what they *charge*, then consumers deciding their preferred selections based on value.
The difference in two cases is as subtle as the difference in outcomes is profound.
"A single-payer system like this is much simpler, far more transparent, and fair."
It may seem so superficially, but single-payer is anything but. Claims still have to be filed, reviewed and approved, but by civil-service workers with platinum pensions who can never be fired, with zero incentive to care about costs, and who earn twice as much as private workers.
It's not more responsive or caring, and it costs a lot more. So, when it has to cost less, they ration until they can fit their (lowered) care allowances into their fiscal budget.
There's absolutely no "transparency" when you mix everyone's money together, and have some faceless functionary dole out from some giant pot. "Transparency" is when your doctor quotes you a price, and you give him/her the money yourself.
I don't understand why that's so difficult for people to comprehend.
And I wonder why people can't understand that bureaucrats enforcing some brutish and crude price-fixing scheme doesn't reduce prices, it just creates scarcity and reduces us all to gamesmanship.
Medicare's a good example. They're inhuman, pay less than doctors' cost, but still consume $9,400 per enrollee annually.
Hmm
(in reply to traveler)
(link...)
"According to CMS, for common benefits, Medicare spending rose by an average of 4.3 percent each year between 1997 and 2009, while private insurance premiums grew at a rate of 6.5 percent per year. "
...
"According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue."
(link...)
Since 2006, the growth in private insurance expenditures for enrollees has outstripped both Medicaid and Medicare rates, and is expected to grow at a faster rate in coming years.
Healthcare does not function
(in reply to traveler)
Healthcare does not function normally in a free-market, capitalist model. Healthcare is something that everyone needs, now or later. Health and, ultimately, remaining alive are things for which people and their loved ones will willingly spend infinity dollars. When you apply market forces of supply and demand to a thing for which the buyer is unable to establish a rational price, the system cannot function. Additionally, the medical profession controls how many people may enter the field, which limits competition. The pharmaceutical and medical devices industries patent their new -and presumably more effective- products, limiting competition. Also, a patient having a heart attack will not shop around for the most economical treatment, she will go to the most proximate resource. A patient with cancer may actually shop around, but for real or perceived effectiveness, not for economy. So you end up with a scenario where buyers will spend everything they have and more, and sellers who have limited competition, with little reason not to charge as much as they can possibly get. Insurers (that's either private or public socialism, kids!) at least have the information and collective clout to create rational buyers' price points for healthcare, so long as they're sufficiently regulated to eliminate their incentive to serve only the healthy while dropping the sick.
Additionally, just as with the automotive example, the unbridled seller is not motivated to cut costs so much as he or she is motivated to increase prices and consumer spending. Completely rational automotive consumers would demand small cars, loaded with safety features and maxed out on fuel efficiency. Instead, manufacturers, knowing SUVs are vastly more profitable, distract consumers away from what's actually in their best interests, by heavily marketing giant, hulking and entirely unnecessary behemoths. Without the intervention of ratcheting-up federal safety standards and federal fuel economy standards, the only thing American consumers could buy would be big, re-styled 1960s technology, careening down the road at 8 miles per gallon.
Likewise, market forces drive the healthcare industry into what is most profitable, not what is most needed by patients. Let's offer up opiates as a prime example of that. That stuff is making profits hand over corpse both within the realm of the who-knows-what-it-costs insured world as well as the cash-on-the-counter world. From a seller's standpoint, the stuff is genius. It creates its own demand! Return customers' own brain chemistry does all the aggressive, guerrilla, direct marketing at the consumers' own expense!
So no, more applied free market economics is not the cure-all for our healthcare ills. You don't even have to get into the usual debates over issues of poverty and other such things. Under a free market healthcare model, there are painfully few incentives to control costs, and so almost everybody is eventually below the poverty line.
I've heard these arguments,
(in reply to Somebody)
I've heard these arguments, but they've never made much sense to me.
Sure, most of us will need some medical care--it's (arguably) "essential." But so is food. And steel--we all use steel. Life depends on it. And energy. And toilet paper, and tires for our cars, and so forth.
But we don't need food and steel and gas and shoe and toilet paper "insurance" to make those things cheaper, do we?
Food is an even more immediate need than medical care--everyone needs it (preferably daily)--and without it you'll die. But that hasn't resulted in food prices soaring out of control.
Quite the contrary, food is *cheap.* Why? Because people shop for value, flock to the best bargains, and so many providers sell food. Pressed by consumers, they've gotten ever better at their business.
You then argue that providers are motivated by profits, not to create and sell what consumers actually need. But, to make profits, you have to sell something people want. To get the highest prices (and thus make the highest profits), you have to offer something that people *really* want or need.
And when you argue about what people really "need"--in whose eyes? Yours, or theirs?
I think you're arguing some wise central planner needs to make sure people get what they really need, rather than what they'd choose for themselves. That's a mistake.
Early in the days of the P.C. I went to a computer fair. I was dismayed to see twenty-three different clone-making Compaq wannabes, all making essentially the same thing. "What a waste!" I thought, "All these companies re-inventing the same wheel, duplicating each other's efforts over and over. What a savings if they could all be combined under one roof, one team..."
Of course I couldn't have been more wrong. Each of those companies added a little something--a twist or a feature--to their vanilla P.C. They all contributed something. And though few of them survived the consumers' scrupulous vetting, their innovations survived and became standard parts of our P.C.s today.
Don't underestimate your fellow citizens, or dismiss them as mere mindless "consumers." They're far more enlightened (and more powerful) than you think. The collective wisdom of hundreds of millions of free people, each deciding what suits them--what serves them and their needs best--far outstrips any smaller group of self-important busybodies.
What serves a particular
(in reply to traveler)
What serves a particular individual's best interests isn't necessarily aligned with what serves the public's best interests. That's why we have a society governed by the rule of mutually agreed upon law.
In your example, a healthy individual refuses to buy health insurance, perceiving it as not needed and a waste of money. This raised the premiums for everyone else who bought insurance.
Then this individual gets hit by a bus and goes to the ER. Because he is uninsured, the cost of the uncompensated care gets absorbed by the provider, raising their costs which again raises premiums for everyone else.
Eventually the system collapses, providers exit the "free market" and nobody can get treatment at any cost. Which wasn't really in the healthy uninsured individual's self interest at all, was it?
The key is to enable each
(in reply to R. Neal)
The key is to enable each person to pursue his/her own enlightened self-interest, provided it comes without making their gain at someone else's expense. That's virtuous, a positive good.
Each of us self-interestedly striving to make our own garden as good as it can be is a very good thing, a public "good." If my neighbor works harder (or smarter) and gets a bumper crop, that hurts me not at all. (In fact it helps everyone--there's now more food available on whole. She'll either sell to others, or buy less at the store, both ways increasing the supply for all.)
If we create a society where people can simply take their "fair share" unearned from their neighbor's garden, then it makes no sense to work extra to produce what you can't keep, nor does it make sense to plant your own garden when you can get the same produce from your neighbor's for free.
insurance ain't corn
(in reply to traveler)
Insurance is not like any other market, even when provided by the private sector. Insurance is based on everyone paying into a pool, even when they are healthy, so that when they are ill they can draw from the pool to pay providers. By it's very nature the insurance market is a collective enterprise.
But we're not actually
(in reply to barker)
But we're not actually talking about insurance, are we? Insurance is something people voluntarily buy to hedge against an unforeseeable event, such as a tornado ripping off your roof.
When you have some third party paying all your ordinary, usual medical expenses, that's no longer insurance, that's become a comprehensive medical payment plan, and then this pretext of us talking about "insurance" falls away. What you're really saying, at that point, is that you want the government to make someone else pay for *all* of your care, as long as you agree to pay for all of theirs.
And that inherently inserts a huge set of middlemen (whether gov't or insurance) into the process of administering and paying for our ordinary care. Unnecessarily.
If we took responsibility for our ordinary needs and reserved insurance for the unexpected expenses, insurance would be cheap, and have less power over our lives. The cost of providing care would fall dramatically, too--eliminating the middle men makes that possible, even without competition or improved delivery.
Which of these is simpler and faster (and more affordable)?
A diagram (I'm not sure how to make the whitespace display properly)
(view in Courier font)
.-----. .-------------.
| You |---$1-->| Your doctor |
'-----' '-------------'
Questions:
Your doctor works for: ______
Your doctor takes instructions from: ______
Who sets the requirements? _______
If you pay $1, your doctor receives ____.
.-----. .-----------. .-------------.
| You |---$1.40-->| Insurance |---$1-->| Your doctor |
'-----' | company | '-------------'
'-----------'
Insurance
(in reply to traveler)
Actually, we are talking about insurance. And under insurance plans, the policy holder, not the insurer, pays for "ordinary, usual medical expenses" through co-pays and deductibles.
No insurance survives without
(in reply to traveler)
No insurance survives without folks that do not use it paying into it.
As I've noted elsewhere,
(in reply to traveler)
As I've noted elsewhere, agricultural economics doesn't work as simply as you seem to think. If what you grow in your garden is a commodity crop, it absolutely can and does hurt you if your neighbor has an unexpected bumper crop and floods the market with it, because prices will drop, perhaps precipitously, and you could end up losing money on your own crop. That's why for some crops the government will pay you not to grow some of your fields, and penalize you if you do it anyway. A year or two of market glut of a crop can put so many farmers out of business that in following years, nothing is planted, prices spike, and people starve.
As it turns out, the sort of enlightened self interest of pure, libertarian capitalism that you've described is every bit the sort of imagined utopia that is pure Marxist communism. Neither thing works because both fail to take into account how humans actually behave and how the world actually works.
Why complicate it so with all
(in reply to Somebody)
Why complicate it so with all those unnecessary external factors?
I was simply pointing out that you, doing what's best for you, is not inherently selfish or zero-sum.
You could grow more vegetables, hurting no one, or you could steal them from your neighbor, gaining at your neighbor's expense.
One of those creates more food for everyone; the other creates less food and pits us against each other, each trying to take what we need from the others (less than zero sum).
The second choice is selfish, the first choice is not.
More balderdash.
(in reply to traveler)
More balderdash.
Food is needed by everyone, but anyone can produce food. You can grow your own in the backyard. Setting issues of poverty aside for the moment, competitive forces will keep food prices down. (I'm also setting aside the screwy economics of agriculture, which also doesn't actually function well in a purely laissez-faire economy. Too good a year, farmers produce too much, prices plummet, and farmers lose money. Too bad a year, farmers produce too little, prices may go up, but not enough to cover costs, and farmers lose money. That's why agriculture has been subsidized and controlled (Socialism!) since the mid-20th century). So anyway, from the consumer side, competition will keep food prices down, outside of famine and disasters. Not so with heart surgery or cancer treatment. Sure, people have had home remedies for millennia, but there was no science behind it, and much of it didn't work any better than whatever crap Gwyneth Paltrow sells at "goop" online. Home visits by doctors bartering for a few chickens didn't offer much more than that, either. They could set a broken bone if the break was simple, and they could tell you you're going to die, but they couldn't do much to stop you from dying.
In the 20th century, however, medical care became a scientific endeavor. Vaccines, antibiotics, and anesthesia made previous death sentences survivable, at a cost. The means of production are very limited, and demand is high, with consumers willing in many circumstances to pay whatever it takes. So no, healthcare is not like steel or food or any other commodities. It is, however, more like infrastructure, which is either socialized or highly regulated by government. Everyone has a need and an interest, and equitable distribution requires something other than the profit motive to make it work.
Again, you keep fluffing over half of the equation. Cancer patients cannot just 'decide what suits them,' and buy whatever treatment they can afford, like they're buying a loaf of bread. Cancer treatment is expensive, and costs more than poor and middle-class Americans can afford. That's why insurance markets were established, originally as nonprofit organizations. Everyone can contribute a little, and only a few actually get cancer, so the money's there to cover the cost for them. It's privatized socialism!
In any case, your description of my fellow citizens simply shopping for healthcare and satisfactorily buying just what suits them is complete and utter nonsense and has no basis in economics or reality. If you've really been studying this stuff, I suggest you study harder, and try avoiding confirmation bias in your research.
These arguments that medical
(in reply to Somebody)
These arguments that medical care is somehow sacred, different, and immune to ordinary forces are silly.
Consumers haven't the slightest conception (much less understanding) of all the physics and engineering and materials science that goes into half the products they buy, yet have no difficulty deciding what they want to buy, and shopping for the best deals.
Medicare is monstrous (and a
(in reply to Tamara Shepherd)
Medicare is monstrous (and a large part of why our non-Medicare healthcare is so over-priced, too).
For one, Medicare payments are so low that many reimbursements are below doctors' costs. To recoup that loss, doctors charge regular patients more. That makes Medicare look cheaper (and ordinary care look more expensive) than it actually is.
Even at those low reimbursement rates, at $540 billion a year to serve 57 million people, Medicare costs about $9,500 per enrollee per year:
Kaiser Family Foundation: The Facts on Medicare Spending and Financing).
That's off-the-charts, despite being heavily subsidized by non-Medicare consumers.
____
On a more human level, a dear relation, a cancer professional, has cancer. Caught early. Well, quasi-early, but aggressive. Not to be put off or played with. But eminently beatable--prognosis / stats are quite good, roughly 90% chance for full recovery with prompt treatment.
Medicare, in its all-knowing ignorance, demands unnecessary (and expensive) tests and consultations, while denying and taking months to approve of the urgently necessary. They put her at terrible risk. She spends hours and hours on the phone, day after day. The people are friendly, all caring and mostly intelligent, but powerless, they explain. And you never get the same one.
Medicare is inhumane, bureaucratic, unresponsive, reckless, and horrendously wasteful; a nightmare.
Medicare's dithering caused delays that could re-ignite her condition (costing us all a fortune for nothing, not to mention the terror of it), or even end her otherwise very good chances of recovery. So she started paying cash instead, then getting reimbursed when Medicare catches up months later. She's doing fine so far, thank you very much. But a less-knowledgeable less-confident person would've been lost in the bureaucracy, if not doomed.
The latest update is that, for an unrelated minor complaint, the dolts have approved an amazingly expensive biologic that is absolutely contraindicated (could set her cancer on fire!), and an MRI of something that just needs a doctor's glance. Incredibly wasteful, but they insist on their way, or they won't pay.
Awful.
______
As to our cost of care, Covenant's CEO, Tony Spezia on local TV a couple years ago (WATE?), said U.S. per-capita health-spending is the same as Europe's, up to age 62. After 62, we spend a lot more.
Much if not most of our higher-than-European per-capita spending, he said, comes from spending more than Europeans to save and care for our elderly. The digging I did at the time suggested he was approximately correct. That means Medicare, mostly, despite their parsimonious payments. They're just awful. And wasteful.
*
(in reply to traveler)
"Universality" is not a "non-medical" criterion to those who can't afford medical care.
And Covenant CEO Tony Spezia earns $1.6 million annually. Talk about your overpaid "bureaucrats"...
*
(in reply to traveler)
Also, I am confused by your contradictory assertions that "Medicare has the highest denial rate" (10:31 pm Sunday) but next that "Medicare... demands unnecessary (and expensive) tests and consultations" (11:56 pm Monday).
Which is it?
The statements are not
(in reply to Tamara Shepherd)
The statements are not contradictory.
In my personal example (which I'm still living each and every day), Medicare denied and or delayed urgently needed tests, surgery, and radiation, while at the same time approving trivial, unnecessary, and even flat-out deadly treatments.
I suggest reading Atul Gawande's paper to get a feel for how poor a health care steward Medicare really is.
(link...)
Also, since we've discussing Medicare, I've included lengthy quotations from a personal transcript I have of Prof. Jonathan Gruber speaking on the topic. (Timestamps are given in case you wish to listen for yourself.)
_______
(link...)
June 23, 2012 FRONTLINE interview on PBS
(video reviewed. Quotes are from PBS' transcript of excerpts)
“If you add up everything we promise to spend in Medicare, Medicaid and everything versus what we were going to collect in taxes, we were, over the distant future, $100 trillion in the hole. Eighty-five trillion dollars of that was Medicare and Medicaid. The entire fiscal health of the U.S. is about health care costs. That's it. Social Security a little bit. Nothing else matters. You know, I like to say in the U.S. there are only two issues that matter, global warming and health care costs, because either way we are under water.” --Prof. Jonathan Gruber
_________
"Medicare is the largest single insurer in America. It insures about 40 million elderly and disabled people. (30:56)
The way they set their rates that they pay doctors is by Congressional fiat. As a result of that politicized process we’ve got a system that’s way out of whack. For example specialists are massively over-compensated relative to primary care doctors." --Prof. Jonathan Gruber, The University of Rhode Island's 2012 Honors Colloquium, Nov. 1, 2012
(link...)
_________
"So insurers on average charge about 15% more than the cost of medical care delivered. (50:35)
Now it could never be zero. Even for Medicare – a government-run insurance plan – it’s one and a half percent. But it’s a lot bigger. And that’s one of the big arguments for single-payer, is we have a lot of administrative costs.
Now to be fair – let’s be fair to the insurance companies for a minute, because I think they’ve been a bit maligned actually. Some of that money is profit, that – you know they probably make more profit than they should. Some of that is wasteful paperwork and that’s a shame. But a lot of the money is actually managing care. So you take Medicare, they have a one-and-a-half percent administrative cost, that’s great. (51:01)
But you know what? Medicare lets doctors do whatever they want and just pay [sic] for it. If you haven’t you should read Atul Gawande’s June 9th 2009 New Yorker article about McAllen, Texas versus El Paso, Texas, comparing Medicare spending in the two communities. The two communities, very near each other, very similar populations, very similar healthcare outcomes. Yet spending is twice as high in McAllen as El Paso. Because they do massive amounts of extra testing, unnecessary work. Okay? And that’s a very popular article. President Obama used to like to cite it.
What a lot of people don’t know is that there was a follow-up article that did the same comparison not for Medicare, but for private insurance. And that comparison found no difference between McAllen and El Paso.
Why? Because Medicare just pays bills. They don’t care. You submit the bill, they pay it. Private insurance looks over your bills and notices if they shouldn’t pay them. That’s part of the 15%. (51:48) And that’s a good part of the 15%.
So in some sense, managed care requires management. (51:53) And management costs administrative dollars. So the notion that the whole 15% is a waste is just wrong. We just don’t know what portion of it’s a waste and what’s not. But we certainly don’t want to say all of it's waste--some of it’s actually doing the management we need to do in order to make healthcare better." --Prof. Jonathan Gruber, ibid.
_______
"If we wanted to bring the Medicare system into balance today, the current 1½% Medicare payroll tax would have to be raised to 12%. Okay? That is the issue. That’s the total issue – for the future of the US economy – is healthcare costs. That’s the single biggest issue beyond anything else." (1:07:14) --Prof. Jonathan Gruber, ibid.
*
News coverage from CBS Pittsburgh pegged the crowd at tonight's 7 pm Save My Care event, sponsored by Move On and headlining Sen. Bernie Sanders, at "more than 1000."
Tomorrow, the tour will deliver events at 11 am in Columbus, OH and at 3 pm in Charleston, WV.
The complete Save My Care bus tour is expected to run two months and cover approximately 20 cities coast to coast.
How Obamacare Helped Slash Personal Bankruptcy by 50%
How Obamacare Helped Slash Personal Bankruptcy by 50%
Obamacare Seems to Be Reducing People’s Medical Debt
Maybe they should just undo this ...
Marco Rubio Quietly Undermines Affordable Care Act
I believe they should instead undo this ...
(in reply to jbr)
Highest-paid health insurance CEO earned $22M in 2016
And it's not just this one (Centene).
Humana's CEO, $19.7M.
Anthem’s CEO, $16.5M.
Aetna’s CEO, $18.7M.
Cigna's CEO, $15.3M (but $17.3M the year prior)
The biggest problem seems to be for-profit insurers (bumping heads with for-profit providers).
Just not convinced it was prudent to have introduced profit motive into the delivery of the public good that is healthcare.
That argument isn't arithmetically sound.
(in reply to Tamara Shepherd)
If we add up all of those, then divide by the healthcare spending they supervise, their salary is a trivial portion. That's not the reason healthcare costs too much.
If you factor in that these people all work aggressively to save money, the argument falls apart completely.