Who'd a thunk it? Obamacare not repealed

[ThisDinosaur]

+1 iDave. That is exactly how I would explain the problem. I would only add that there is a widespread assumption that everyone is entitled to expensive care. No healthcare provider in this country would want to be caught telling uninsured parents of a premie kid that their newborn isn't entitled to the same care as a rich baby. As much as I hate the use of the word "entitlements" in political discussions, there is still a reality that this stuff isn't free. The people who work in hospitals and supply them with equipment, do it so they can pay their bills.

[IlliniDave]

@IlliniDave
...
I have come around to creating a single payer system. The costs vs results are all in favor of it.
...

Reluctantly, that's where I seem to be going too. My inner libertarian is howling and clawing his eyes out. But my inner engineer, the troubleshooter and problem solver, can't get past it. I still like a hybrid system best, something where taxpayers fund everything above a certain level per year (maybe after a $10K-$20K deductible) and let the commercial industry offer plans to cover some fraction of the deductible depending on how much a customer wants to buy. You could add assistance for lower income folks to buy some of the additional coverage, and have a need-based program to assist the chronically ill who would be expected to hit the deductible every year and mess up the risk pools the insurance companies are working with. Wont be cheap to the taxpayer, but it does keep some skin in the game for most people while protecting most everyone from ruinous medical bills.

[Chad]

@IlliniDave
Yeah, that was kind of my inner monologue too. The more I examined it the more it became apparent that healthcare doesn't function well within normal business rules/systems.

I would argue that the idea of a single payer type system costing way more seems out of line with the long-term examples we have in the European countries, Canada, and Japan.

Healthcare cost as % of GDP:
Belgium 10.6%
Canada 10.4%
Denmark 10.8%
France 11.5%
Germany 11.3%
United Kingdom 9.1%
Japan 10.2%
US 17.1%
http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS


That's a big difference and gets even bigger when you factor in the much higher GDP per person in the US than the other countries:
Belgium $44.9k
Canada $46.2k
Denmark $46.6k
France $42.4k
Germany $48.2k
United Kingdom $42.5k
Japan $38.9k
US $57.3
https://www.cia.gov/library/publication ... 4rank.html

So, we spend tons more money, but rank last in results among these countries:
https://www.forbes.com/sites/danmunro/2 ... 52f46f576f

Even if we could get the costs to the level of the "evil socialist" French we would be getting better results for less money.

The problem, as with everything of this type, is getting the political bullshit out the way to have a real discussion based on real numbers to find out what we actually want, need, and can have.

[IlliniDave]

+1 iDave. That is exactly how I would explain the problem. I would only add that there is a widespread assumption that everyone is entitled to expensive care. No healthcare provider in this country would want to be caught telling uninsured parents of a premie kid that their newborn isn't entitled to the same care as a rich baby. As much as I hate the use of the word "entitlements" in political discussions, there is still a reality that this stuff isn't free. The people who work in hospitals and supply them with equipment, do it so they can pay their bills.

Actually, I think "entitlements" gets misused a lot. It is often used (correctly, I believe) for things like SS and Medicare, that through a working lifetime of paying into/participating in, we in effect earn a right (entitlement) to, but people hear it and think "free government handouts". But that's a quibble.

I would tend to phrase your third sentence that people assume everyone should have access to the best appropriate medical care available given their medical situation. In other words, if two babies arrive at the same NICU at the same time in identical condition, they should receive the same care--the best effort the facility can put forth for the condition (which in the US is almost synonymous with expensive). That should be true regardless of socioeconomic situation of the babies' parents.

At the same time there's one orthopedic surgeon in the country who is the very best, and the taxpayer should not be expected to send every person in need of relevant surgery across the country to that one doctor when there are hundreds or thousands of other surgeons who can complete the procedure with complete efficacy. That won't stop people with enough money from undertaking the expense out-of-pocket and seeking out things they perceive as better. Point being, there has to be some rational limits built into the taxpayer-funded portion of a system. If you have enough money/power/connections, you can get stuff many other people can't.

[Chad]

Except, I'm not a socialist. I try to not be anything, as every type of tool seems to come in handy at some point. My goal is to use what is best. In this case, it appears to be a more socialist like system. This does not mean I'm not fine with rapacious capitalism in other industries.

[IlliniDave]

@IlliniDave
...
I have come around to creating a single payer system. The costs vs results are all in favor of it.
...

Reluctantly, that's where I seem to be going too. My inner libertarian is howling and clawing his eyes out.

I feel like healthcare is the most common entry point for people to become socialists. Leveling power of death and all.

Possibly, and that's probably why we'll always have a nightmarish healthcare landscape in this country. Many would argue it's the lesser evil and that we're already closer to the slippery slope than is wise.

[IlliniDave]

Except, I'm not a socialist. I try to not be anything, as every type of tool seems to come in handy at some point. My goal is to use what is best. In this case, it appears to be a more socialist like system. This does not mean I'm not fine rapacious capitalism in other industries.

That's a good point. In theory it should be possible to reach into the toolbox without donning the ideology--to use a hammer without seeing the entire world as a bucket of nails.

[ThisDinosaur]

@scriptbunny
In a totally free market, someone would still invent insurance companies. The more expensive the potential loss, the larger the pool has to be for insurance to be worthwhile. The next logical step is a single massive mutual insurance company to cover the losses of the unlucky few. Its a long (but slippery) way from that to "from each according to his ability...."

[jacob]

First, I would like to state my appreciation for keeping this thread so informative and civilized!

Second, while a lot of the snafu is due to the inherent difficulty of solving a complex construct (nobody knew ...), there's definitely some ideological barriers that have to be crossed in the general public before those who do know can get the green light. Such ideological barriers are often strangely idiosyncratic in the sense of rejecting any idea that's branded the wrong way, e.g. socialism.

From an international/outside perspective, there are some Americans willing to consider adopting the solutions of other countries and others resisting it because it would be socialist and include death panels or something else. However, I've yet to encounter any non-American expressing any desire to make their health system more like the US health system(*). Not a single one ... This is interesting, no?

(*) E.g. cutting taxes and switching to an insurance based system.

I'll also note that road building and maintenance in the US is run very much like one of those socialist single-payer systems, except of course we don't call it that. All US public roads are paid for by taxes. Everybody can drive on them. While some people drive a lot on the roads and some never drive, very few are motivated to go out and drive as much as possible just because the roads are free (<- paid for by others). By far the most will just use the roads when they need them and for what they need them for. Also, you can use the "public option" state roads to get wherever you want and that works for most traffic. In some select cases, if you want to go faster, there are private toll roads where you can pay extra for the speed and luxury.

You can probably imagine how using the US roads would be like if they were run more like the US health care system. Each segment would be randomly priced and you wouldn't hear the price until after you crossed (the gate operator really has no idea and just wants to open the gate and send you along in comfort). Before starting your car, you would be presented with a form to sign whether you had any financial concerns about your trip possibly bankrupting you. You might pay $0.10 to drive a given stretch but the next stretch would be charged at $55,000. A few months later, you'd receive 4-12 bills from different road operators for use of service. And so, to avoid that, you buy "road pricing insurance" and soon an entire industry would be built up around trying to price the many many various streets and roads. You can imagine the job creation that would result in. Lots of toll road managers and gate keepers, billing services, ... One could easily make road-related GDP twice as high as it is now

[Chad]

@jacob
Completely agree with your second point about ideological barriers. Why can't we talk about new taxes and what things actually cost (social security)? Why can't we talk about certain conditions (smokers, overweight, etc.) paying a little more (not born with X condition)?

I really like your highway example. Easy to understand. I'm using that myself going forward.

[Chad]

@scriptbunny
Definitely a big part of the problem.

[jennypenny]

That's the problem I have with basing cost on lifestyle and health status. It's been shown that the poorer a person is, the more likely they are to be overweight. They are also more likely to be exposed to toxins like lead in paint and generally receive sub-standard educations, both of which can contribute to poor decision-making skills as an adult. Do we penalize them for growing up poor? I dunno.

Maybe we can impose conditions on receiving their healthcare? It's been shown that overall costs to states are lower if they send drug offenders to rehab instead of jail. It's also a more compassionate approach than penalizing them even though the second me seem more 'just' to some people. I could see mandating education and PT/exercise for patients as a part of their treatment for lifestyle diseases. My guess is that the lifetime costs for those individuals would go down and (hopefully) their quality of life would go up.

[Chad]

I don't disagree. I could easily be talked out of the idea of making people with certain conditions pay more. Your arguments definitely have merit. Being poor does predispose you to the issues you noted and the goal should be to help these people live a better life at the lowest cost to everyone else.

Reaching this goal sometimes requires solutions that sound counter to what we are trying to do. Your drug offender situation is an example along these lines.

The example I would point to is Utah's fight to end homelessness:

"Ironically, ending homelessness is actually cheaper than continuing to treat the problem. This would not only benefit the people who are homeless; it would be healing for the rest of us to live in a more compassionate and just nation,"

http://www.motherjones.com/politics/201 ... sness-utah

Maybe the conditions you suggest (education, exerciese, etc) would work. My worry with stuff like that is it ends up being more expensive, as you would need people to monitor them. But, maybe not. The costs would need to be detailed out.

[IlliniDave]

That's the problem I have with basing cost on lifestyle and health status. It's been shown that the poorer a person is, the more likely they are to be overweight. They are also more likely to be exposed to toxins like lead in paint and generally receive sub-standard educations, both of which can contribute to poor decision-making skills as an adult. Do we penalize them for growing up poor? I dunno.

Maybe we can impose conditions on receiving their healthcare? It's been shown that overall costs to states are lower if they send drug offenders to rehab instead of jail. It's also a more compassionate approach than penalizing them even though the second me seem more 'just' to some people. I could see mandating education and PT/exercise for patients as a part of their treatment for lifestyle diseases. My guess is that the lifetime costs for those individuals would go down and (hopefully) their quality of life would go up.

Same argument can be made for the older, pre-Medicare demographic. Even ACA allowed insurers to charge them 3X more than younger people. With the new bill that would be raised to 5X.

I'm of a mixed mind on rate differentiation. I don't consider it punishment, just a reflection of statistics. Once you get to income levels where people have the wherewithal to shoulder a little more of their own costs, they probably should.

For the record, I have a history of one of the conditions being floated around in a list* FB by my hysteria-consumed liberal friends as "preexisting conditions that will cause you to be denied healthcare by Trump".

That reminds me of another aggravation I have with this bill, that some of the more significant provisions hinge on whether a given state applies with a waiver and how they meet the conditions of the waiver. For example, if a state waves community pricing they are required to set up and manage a high risk pool. So now we're headed to a patchwork of solutions making it impossible for anyone to know what's going to happen to them in the event the bill passes.

*Edit to add: I did some checking and it appears that the list I alluded to above is a fabrication, as are many other things being speculated about (including on news media) as items people will lose healthcare (not just insurance coverage) for. Even if the bill passes no one will know how that will play out for them until they see how their state decides to handle things going forward.

[Spartan_Warrior]

Single payer actually does put downward pressure on health care costs overall, through multiple mechanisms.

http://journalofethics.ama-assn.org/201 ... -1211.html

[Dragline]

I tend to agree with Krauthammer's analysis -- single payer is almost inevitable due to the change in framing of the issue:

"CHARLES KRAUTHAMMER: I think historically speaking we are at the midpoint. We had seven years of Obamacare, a change in expectations. And I would predict that in less than seven years, we will be in a single-payer system. I think that's the great irony of this.

Obamacare failed at every level. Politically, the Democrats were crushed over six years and four elections, whereas you say, they lost seats in the House, the Senate, the governorships, etc. largely because of Obamacare.

It failed on the ground, as was pointed out earlier. The insurers are in a death spiral. The Obamacare exchanges are collapsing. You've had these exchanges, these community exchanges completely disintegrating. But the irony is in the end, I think Obamacare wins the day because it changed expectations. Look at the terms of the debate. Republicans are not arguing the free market anymore. They have sort of accepted the fact that the electorate sees health care as not just any commodity. It's not like purchasing a steak or a car. It is something people now have a sense that government ought to guarantee."

http://www.realclearpolitics.com/video/ ... ystem.html

And it goes along with my confirmation bias about a Fourth Turning and Millennial values replacing those of the dead and dying.

[Chad]

I agree. Krauthammer is more right than wrong.

It's interesting that Obamacare is blamed or given much of the blame for the Democrats defeat, while the Republicans are getting hammered by a lot of their supporters for trying to do what they said they were going to do for years. This just seems to support the teams theory, and the dislike of Obama.

Of course, considering the strong support for Obamacare from the general population, it's hard to figure out why there was so much dislike for him when his signature legislation can't even be done in by a Republican controlled gov't. So, then, why the dislike of Obama? That's rhetorical.

[BRUTE]

However, I've yet to encounter any non-American expressing any desire to make their health system more like the US health system(*). Not a single one ... This is interesting, no?

no humans in this thread have argued that the current US health system is great. humans that are against single payer usually don't argue that what exists is good - but that a move should be made in the opposite direction, towards free markets. insofar, this argument is a straw man.

I'll also note that road building and maintenance in the US is run very much like one of those socialist single-payer systems, except of course we don't call it that. All US public roads are paid for by taxes.

maybe that's why the roads are in such terrible condition, never get fixed, despite constantly being under construction?

does jacob really want the humans who run the USPS operating on him?

brute is quite certain that a single payer system would solve none of the problems the US health care system has. there are cultural differences between the US and other western nations that will likely be exacerbated by a single payer system.

just like "imposing" a free market didn't work on the former USSR, and "imposing" democracy didn't work in Iraq, "imposing" a single payer system on US health care will not make health care affordable, accessible, or even available for those who currently don't have it.

[Dragline]

[
brute is quite certain that a single payer system would solve none of the problems the US health care system has. there are cultural differences between the US and other western nations that will likely be exacerbated by a single payer system.

just like "imposing" a free market didn't work on the former USSR, and "imposing" democracy didn't work in Iraq, "imposing" a single payer system on US health care will not make health care affordable, accessible, or even available for those who currently don't have it.

What are the cultural differences? Is there any cultural difference to providing health care for old, really poor and disabled people to expanding coverage for all people?

And what if the single payer is actually allowed to negotiate with providers, for which Medicaid/Medicare is currently not allowed to do with drug providers?

[BRUTE]

specifically, brute was thinking about a culture of over-diagnosing, over-prescribing, over-litigating, undervaluing lifestyle, a tendency for pill-popping and silver bullet solutions... all these things will be demanded by US health care consumers under single payer, and they'll be done by US medical professionals and US lawyers.

sure, there might be a few efficiencies with a single payer system. there might also be a few inefficiencies, as is often the case with non-market-based solutions.

in general, government solutions seem to be good at arresting development. brute is unsure the current state of US health care is worth arresting. if possible, brute would favor rolling the dice on Jan 1st every year, and introducing a completely random, new health care system for that year. and then see what sticks.