Who'd a thunk it? Obamacare not repealed

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Chad
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Re: Who'd a thunk it? Obamacare not repealed

Post by Chad »

Another point in favor of single payer is that businesses would love to not be responsible for healthcare insurance. Especially, small businesses.

OTCW
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Re: Who'd a thunk it? Obamacare not repealed

Post by OTCW »

Chad wrote:
Mon May 08, 2017 2:48 pm
Another point in favor of single payer is that businesses would love to not be responsible for healthcare insurance. Especially, small businesses.
Some would. Others view offering good benefits as a way to recruit and especially retain good employees. I'd guess most employers would still want to offer insurance as part of their compensation packages, but wish the costs were lower to do so.

classical_Liberal
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Re: Who'd a thunk it? Obamacare not repealed

Post by classical_Liberal »

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Last edited by classical_Liberal on Thu Feb 04, 2021 11:07 pm, edited 1 time in total.

IlliniDave
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Re: Who'd a thunk it? Obamacare not repealed

Post by IlliniDave »

OTCW wrote:
Mon May 08, 2017 3:07 pm
Chad wrote:
Mon May 08, 2017 2:48 pm
Another point in favor of single payer is that businesses would love to not be responsible for healthcare insurance. Especially, small businesses.
Some would. Others view offering good benefits as a way to recruit and especially retain good employees. I'd guess most employers would still want to offer insurance as part of their compensation packages, but wish the costs were lower to do so.
One thing I wonder about is if the employer mandate is reversed, whether a lot of companies won't take the opportunity get out of the medical insurance game simply because of the rate of increase in the cost. I know for my entire career my company has been back pedaling: reducing coverage and increasing employee contributions. Not many businesses consistently grow revenue as fast as medical costs go up. I'm sure many would like to continue, but as fewer and fewer competitors do the benefit of it wanes, much like pension plans, and it eventually becomes more of a liability on balance.

Chad
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Re: Who'd a thunk it? Obamacare not repealed

Post by Chad »

@IlliniDave

It's possible. The cost and administration of health insurance is annoying for most businesses. Plus, you just make your workers unhappy most of the time. Taking that responsibility and offloading it would free up the business a little.

OTCW
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Re: Who'd a thunk it? Obamacare not repealed

Post by OTCW »

IlliniDave wrote:
Mon May 08, 2017 3:33 pm
OTCW wrote:
Mon May 08, 2017 3:07 pm
Chad wrote:
Mon May 08, 2017 2:48 pm
Another point in favor of single payer is that businesses would love to not be responsible for healthcare insurance. Especially, small businesses.
Some would. Others view offering good benefits as a way to recruit and especially retain good employees. I'd guess most employers would still want to offer insurance as part of their compensation packages, but wish the costs were lower to do so.
One thing I wonder about is if the employer mandate is reversed, whether a lot of companies won't take the opportunity get out of the medical insurance game simply because of the rate of increase in the cost. I know for my entire career my company has been back pedaling: reducing coverage and increasing employee contributions. Not many businesses consistently grow revenue as fast as medical costs go up. I'm sure many would like to continue, but as fewer and fewer competitors do the benefit of it wanes, much like pension plans, and it eventually becomes more of a liability on balance.
Could be. I don't think anyone wants to pay for it.

Riggerjack
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Re: Who'd a thunk it? Obamacare not repealed

Post by Riggerjack »

The reason we have employer health benefits is because the WPA limited pay, and as a work around, businesses started moving into benefits packages to compete for skilled workers. This proved so popular, it got encoded in the tax code, twice. (Still part of the 1986 tax bill.

With obamacare, there was a chance for insurance to expand coverage without moral hazard. Now, health insurers could sell to the general public, without fear that they were only getting people with existing conditions. Before 2008, insurers went with pools of employees, to guard against moral hazard, so now, insurers no longer need employers. If insurers get this right, I doubt they will continue to cut breaks to employers.

But there is still the tax break. If employers dump health insurance benefits, employees will expect to be compensated for their increased costs. But then they will have to pay premiums with after tax money. Which means compensation would need to nearly cover the same costs, after tax.

Until the tax code changes, companies that currently provide health insurance will continue to do so. A few will try to get out of it, but this won't be a trend, unless the red team hits us with their best shot, always a possibility, I guess.

IlliniDave
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Re: Who'd a thunk it? Obamacare not repealed

Post by IlliniDave »

Riggerjack wrote:
Mon May 08, 2017 7:19 pm

Until the tax code changes, companies that currently provide health insurance will continue to do so. A few will try to get out of it, but this won't be a trend, unless the red team hits us with their best shot, always a possibility, I guess.
I think a lot of moderate/medium sized companies that were forced into providing healthcare by ACA will bail en masse. Larger companies that have provided medical for decades are like the rest of us and wonder how long they can afford to keep it up, although the new bill opens the door for states the lower the bar in terms of defining coverage minimums, which might mitigate things some. I certainly wouldn't expect my employer to reinstate the "Cadillac" options they've scuttled in the last couple years. The irony is those so-called Caddy plans were only a wan reflection of what was offered 20-30 years ago.

As far as making it equitable for employees (something that doesn't always happen when benefits are scaled back) it depends on a few things. At one time the repeal/replace plan was going to open HSAs to all and allow them to be used free of penalty for premiums, and that premiums in general were going to be deductible. If all that holds, employers can hand employees the same money they're spending now (maybe some/all in an HSA) and wish them good luck. The rub is younger, healthier, single employees will make out better and older less healthy employees with dependents/spouses will come out worse in most cases if they live in states that opt for the community pricing waiver and suddenly, unlike the egalitarian microcosm of the employer pools, they will be charged according to their age and other perceived risk factors. And with no individual mandates, there is nothing to stop the employees from using the money to take a vacation to Costa Rica.

It's all fun to speculate about, but we won't know much until we see what happens in the Senate. There are mixed opinions on what will happen there.

Riggerjack
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Re: Who'd a thunk it? Obamacare not repealed

Post by Riggerjack »

I may have been unjustiably hash about single payer systems. Odds are, most medical treatment is going to be the same, regardless of pay system.

You break your arm, they x-ray it, and put it in a cast. You go home and watch TV, or go home and fight with insurance, or go home and cook cabbage stew before going back to work camp, or whatever. The point being in 80-90% of cases, the care you receive is the same. The difference is in those 10-20% of nonstandard cases.

Let me tell you about my last visit. My wife strained her neck gardening. This happened Saturday, and it wasn't better by Tuesday, so we slipped into urgent care after work. The doc does her thing, and it's probably just a sprain of the Atlas, but to be sure it isn't an aneurysm in the brain, we went and had an MRI done. This is what is different with a single payer. At some point, a bean counter will decide that in almost all cases like this, it isn't an aneurysm, it is just a sprain, and they just won't do them. No big deal, this only happens to a few people, and most of them are fine, either way. Oh, sure, maybe 1% who did what they were told by their doctors will die of a stroke, but it is hard to connect the stroke to the undiagnosed aneurysm, to the sprain. The story afterward is she probably had a small stroke Saturday, and then the big one. Or it was just a sprain, and the stroke was just an unpredictable event.

But we are insured to the gills, and have reserves, I want the scan.

Now some will look at that story, and talk about the wasted scan, that we should fix the system by eliminating unnecessary tests. I, having years if troubleshooting, know that you need the tests, both positive and negative to do a proper diagnosis. So my focus is on why an MRI is so much more expensive here than in a 3rd world hospital.

The answer is of course, in the 3rd world, they still have relatively free medical markets. Key word, relatively. I know about Mexico, where free medical is available, and exactly as fast and helpful as you would imagine a free Mexican system to be. But I know there is another system, open to tourists, foreigners, and their wallets. In that system, MRIs are cheaper than in the States. Because, you are billed for your MRI, not your MRI, some of Betty's x-ray, and Bob's colonoscopy. So long as hospitals are writing unpaid bills off on other patients bills, there is no addressing healthcare costs.

I work in telecom. Prior to the telecom act of 1996, it was common for most local service providers to Bill on a cost plus basis. We would total all the costs of providing service, add a predetermined percentage of profit, then divide that among subscribers. Fair system, right? 6% profits, no gouging, everybody wins. Yay, regulation. Then, some bright young executive realizes that since profits are a percentage if costs, if costs go up, profits go up. Hire more people. Buy more equipment. Eventually, make your supply chain go through the national organization, rather than the local one. Now you can tack on any charge you want to any local provider, pocket the profits, and they add them to their costs, so it results in higher rates, and more profits for the local provider! This isn't clever, or unexpected, everyone did it. It was clear from the day the local franchise agreement was signed that this is how it would work out. Every signer knew this was the game plan.

This is what a cost plus model gets you. This is how regulation works. This is how our medical billing system works. This is how it is supposed to work. There is no part of this that is a surprise, or unintended. Decide for yourself how much more you want.

BRUTE
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Re: Who'd a thunk it? Obamacare not repealed

Post by BRUTE »

OTCW wrote:
Mon May 08, 2017 2:10 pm
Back to healthcare...as costs have skyrocketed (for lots of reasons), it is no wonder we spend all this effort on deciding who is going to pay for what. Get costs under control, and a shared solution gets a lot easier to construct IMO.
this fucking guy :D completely agreed.
OTCW wrote:
Mon May 08, 2017 2:10 pm
So my focus is on why an MRI is so much more expensive here than in a 3rd world hospital.
brute has the same experience. he's walked into emergency rooms in South East Asia, and got out an hour or two later with several types of opiates and much more. total cost, less than $110 (brand name drugs, locals later told brute he'd been ripped off and should have insisted on generics). they asked if brute wanted to use insurance, but at that price.. why bother.

non-emergency consultations even cheaper. <$30 for a 30 minute consultation with a western educated (not that that's necessarily better, but this doctor had a British accent) doctor.

why is health care there so cheap? because [edit: many of the longer-term care for seniors'] health care is provided by families, and the populations are younger and healthier on average than in the west.

ThisDinosaur
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Re: Who'd a thunk it? Obamacare not repealed

Post by ThisDinosaur »

Riggerjack wrote:
Mon May 08, 2017 8:21 pm
Because, you are billed for your MRI, not your MRI, some of Betty's x-ray, and Bob's colonoscopy. So long as hospitals are writing unpaid bills off on other patients bills, there is no addressing healthcare costs.
Exactly. And I'll add to that the high malpractice insurance costs of the doc /hospital that once decided to skip the MRI to save cost and resources and missed an aneurysm.

Lemon
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Re: Who'd a thunk it? Obamacare not repealed

Post by Lemon »

Apologies if this is becoming too off topic

@Jennypenny No presumption taken. What classical liberal said in essence covers my feeling on this, money isn't a great motivating factor and making things more sociable is the way to go. Even my country hours are probably the worst bit of the job and compared to the US we look like layabouts.

@Classical_liberal. You rant on EoL care is pretty spot on, but it isn't just distant family. Some people really want everything because 'they have seen it work for others' Perfoming CPR for an hour on a 20 year old with a pulmonary embolism is very different from doing the same on an 80 year old with heart failure, end stage lung disease and metastatic cancer but people don't seem to see that, even here. I would love to live in a world where the attitude taken in this town is spread out and becomes culturally normal: http://www.npr.org/sections/money/2014/ ... crosse-wis people get better end of life outcomes and it is cheaper. Win win if you can get people over the taboo about talking about death.

@IlliniDave I in essence agree. My point was how healthcare is given has to be changed to be affordable in a single payer system

Chad
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Re: Who'd a thunk it? Obamacare not repealed

Post by Chad »

@Riggerjack

The problem with the example you use about your wife is that their is another side to all these tests. You find stuff you don't need to find or it's misdiagnosed, which then creates its own damage, pain, etc. The overall end result for the population could be the same or even worse with the tests.

Another point is sometimes someone just needs to tell us to stop. I know that was probably the case when my mother had brain cancer.

I'm also sure the cheap MRIs in Mexico aren't just the result of a free market. For sure, some of it is, but much of healthcare really can't be a free market. When I'm I going to get to use the knowledge I have now about brain cancer in determining treatment? Probably never and that is true for many healthcare services.

Part of it is also, the country in general costs less than everything in the US, Dollar vs Peso valuation, probably don't have to meet certain standards, services like this (https://well.blogs.nytimes.com/2012/07/ ... care/?_r=0 ), limit the type/health of people who have access, etc.

But, you are correct that this, " So long as hospitals are writing unpaid bills off on other patients bills, there is no addressing healthcare costs." is one of our major problems. There seem to be only two ways to fix it; not provide healthcare to these people or create a single payer type system.

In reality, the majority of the people aren't going to say "no" to people that can't afford it, so we are going to pay for this stuff anyway. Why not put in a system modeled on systems that have proven they cost less? Oh, I know it's unlikely we would get that system. God forbid anyone actually pay taxes or willingly create a government program without one side sabotaging it based on some arcane belief system. Just look at what is going on with healthcare currently. They don't have the balls to actually cut it, so they put artificial hurdles in to force people out of it and it won't cost us any less because of the above paragraph. But, we have to try, as there really isn't another option.

BRUTE
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Re: Who'd a thunk it? Obamacare not repealed

Post by BRUTE »

Chad wrote:
Tue May 09, 2017 8:27 am
In reality, the majority of the people aren't going to say "no" to people that can't afford it, so we are going to pay for this stuff anyway.
just like taxes, the current system (and most, really) creates an incentive trap. if asked on a case-by-case basis, most humans would very likely NOT pay a lot of money for the health care of other humans they've never heard of - close friends and family, sure, plus insurance where it makes sense.

but through the incentive structure, all humans are incentivized to take the maximum amount out of the system, while making it nearly useless for a single human paying into the system to try and reduce his payment into the system.

classic tragedy of the commons.

also, "in reality", society cannot afford this. as much as some (here) like to ignore this point, there is a finite amount of goods and services to go around in the economy, and printing money doesn't increase it, only redistribute. currently, even the richest country in the world is not rich enough to afford Medicare for the entire population - even the current level of medicare (and similar programs) is not sustainable.

thus, the health care (not insurance premiums) has to get a lot cheaper. either by reducing prices, or by reducing services ("death panels").

demanding "Medicare for all" or similar single-payer schemes without first fixing the underlying cost issues is like driving a car very fast towards a cliff, exclaiming that "everything went super well so far".
Chad wrote:
Tue May 09, 2017 8:27 am
Why not put in a system modeled on systems that have proven they cost less? Oh, I know it's unlikely we would get that system. God forbid anyone actually pay taxes or willingly create a government program without one side sabotaging it based on some arcane belief system. Just look at what is going on with healthcare currently. They don't have the balls to actually cut it, so they put artificial hurdles in to force people out of it and it won't cost us any less because of the above paragraph. But, we have to try, as there really isn't another option.
single-payer in the US has proven to be financially unsustainable (Medicare) or so crappy nobody wants it (VA, Medicaid).

it really is simple. the total cost of health care is Cost of services * Services rendered = Total Cost. if cost of services is not reduced, services rendered will be reduced. maybe "Death Panels" is a strong word for this, but reduced care is reduced care. obviously, the humans now benefitting from subsidized high-quality health care (employees and Medicare recipients) don't want their health care to degrade.

sometimes, brute thinks that politics is just an elaborate way to trap other humans in incentive traps against their own interest.

Tyler9000
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Re: Who'd a thunk it? Obamacare not repealed

Post by Tyler9000 »

This has been making the rounds lately. I like that it focuses first and foremost on fixing the cost problem, as that's the only foundation that makes sustainable sense to me.

https://market-ticker.org/akcs-www?post=231949

IlliniDave
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Re: Who'd a thunk it? Obamacare not repealed

Post by IlliniDave »

Tyler9000 wrote:
Tue May 09, 2017 11:23 am
This has been making the rounds lately. I like that it focuses first and foremost on fixing the cost problem, as that's the only foundation that makes sustainable sense to me.

https://market-ticker.org/akcs-www?post=231949
That's a tad ambitious. So I think what we're saying is that we'll never get there from here with the "healthcare issue". :) It's another "drain the swamp" project.

Riggerjack
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Re: Who'd a thunk it? Obamacare not repealed

Post by Riggerjack »

We had a working medical system. Then, we added insurance which raised costs. After all, adding insurance doesn't do anything to improve healthcare, and adds administration both to the provider and it's own admin and profit. This is what I meant when I said insurance is the most expensive way to pay for something.

Now we have several single payer proponents. People who seem to believe that by restricting the insurance costs to a single payer, you have somehow solved the problem. Well, if you define the problem as one half of insurance admin costs, this makes sense. It probably does.

But as I have pointed out above, there is cost shifting going on. The system is designed to extract and obfuscate profits, who pays part of the insurance admin costs is a distraction, not a solution.

But that isn't my objection. A few percent here or there really means next to nothing in the end. But the bigger the distance (in people) between decisions and effects, the more wrong decisions get made. This is just an observable trait in every organization. Central planning only works for the planners, and eventually, not even them. So, while a single payer will initially decrease costs, slightly the very inefficiencies of the system will soon outpace the small admin savings.

In Europe, and the VA and Medicare, this is handled by artificial limits on quantity (long waits) and quality, (fewer MRIs, so more diagnosis by other means). I'm OK with that. I don't live in Europe, escaped military medicine mostly intact, and if I find myself on Medicare, I will have other resources, and I'm not very good at accepting expert opinions unchecked.

But when I hear folks advocating single payer for all, I have a harshly negative reaction. One that makes me less than receptive to other viewpoints.

So, Chad, Spartan Warrior, Dragline, help me out here. I tend to dismiss your enthusiasm for singlepayer as you mashing your ideals against the reality we live in, and when they don't fit, concluding that reality is wrong. I have done this myself, it isn't comfortable.

So given that there IS cost shifting going on, and that single payer is only capable of fixing part of one side's administrative costs, and that any change a single payer system makes WILL be adapted to by cost shifting, how do you justify it? What makes this a working solution? Because I just can't see it.

IlliniDave
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Re: Who'd a thunk it? Obamacare not repealed

Post by IlliniDave »

@Riggerjack. I think removing profit from the administration of pooled funds (be it one pool or many) eliminates one pretty significant conflict of interest inherent to the system. We need a Jack Bogle of medical insurance!

I'm neutral to a centralized system insofar as I'm willing to listen to the case for it. One thing people forget about or minimize is that even with such a system the system only limit's what the pooled funds will pay for. Most Americans, if they make it a financial priority, could pursue additional diagnosis or optional procedures (especially of the "everyday" variety). There's still the issue of the poorest out there who truly couldn't come up with a few hundred bucks for a one-time discretionary MRI or whatever, so without allowance for that there's the danger of a medical caste system forming. But I think most of the wealthy single-payer countries out there people can supplement the system if they are willing to pay 100% of the service cost. Just have to make sure the basic coverage is reasonably adequate (which also means fiscally responsible to the general public).
Last edited by IlliniDave on Tue May 09, 2017 2:18 pm, edited 1 time in total.

ThisDinosaur
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Re: Who'd a thunk it? Obamacare not repealed

Post by ThisDinosaur »

@Riggerjack
Not to speak for those you listed, but single payer's obvious utility is in catastrophic coverage. You can shop around for your knee replacement surgeon. You can't shop around for your ICU if you get hit by a bus. That stuff bankrupts people and there is no way to get *actual* costs of a stay in intensive care any lower. So insurance/single payer will spread the risk because most of us won't ever be hit by buses.

Dragline
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Re: Who'd a thunk it? Obamacare not repealed

Post by Dragline »

I disagree with the premise that we had "working medical system". That's a Golden Era fallacy. It worked for some people. It didn't work for a lot of other people. It didn't work for people trying to buy medicine that turned out to be poison. That's why there is an FDA. It didn't work for veterans with unique problems. That's why there is a VA. It didn't work for old people who were living longer but couldn't afford their chronic conditions. That's why there is medicare. It didn't work for the destitute. That's why there is medicaid. It didn't work for a lot of working people. So the government artificially incentived employers to provide it. It became expensive as treatments and options improved. Insurance markets developed and were treated like other forms of insurance that are traditionally regulated by the states. These programs did not appear out of thin air for no reason. Moreover, the kind of high-tech medicine that is available now never really existed before our lifetimes either.

But I don't think this is really a philosophical question at this point, but simply a practical one of realpolitik.

We already have multiple single payer systems and layers of Parts within them. You just have to be broke, a veteran or old to qualify. Unless you are advocating getting rid of Medicare and Medicaid and special VA medical benefits -- which is a defensible position philosophically but a complete nonstarter otherwise -- the realpolitik, or practical solution is increase efficiency is to combine these things into one program and expand them to cover everyone, especially the young and relatively healthy, and to get rid of the artificial incentives for employers to provide health care as a benefit. And then allow that program to do things like actively negotiate drug prices, which Medicare is presently prohibited from doing by law to protect the pharmaceutical industry.

Nobody is saying you wouldn't be able to "buy more health care" or supplemental insurance if you want it, as some people do now, so I don't see why you should have a negative reaction to what other people may not be able to do while you have other resources to get additional care if you want it. "Executive Health Care" is likely to thrive in such an environment and should be extremely competitive because it could be largely unregulated. Just because some people take the bus does not mean you can't hire a limousine or a helicopter if you really want it.

And now for a friendly "Death Panel": :twisted: :twisted: :twisted: :twisted: :twisted: :twisted: :twisted:

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