Author Topic: What comes after the ACA?  (Read 243269 times)

EnjoyIt

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Re: What comes after the ACA?
« Reply #1850 on: April 06, 2017, 02:05:30 AM »
I think there is a lot of confusion in the US about health care delivery systems and the terminology attached to them.

Maybe if some more republicans go on TV and shout about DEATH PANELS often enough, that will clear things up for everybody.

Or if more Dems keep chanting, "Single payer!  Single payer!"

Neither side is presenting a cogent, contextualized, rational position.  There's no "right side" in the US political system regarding healthcare at this moment.

I couldn't agree more.  Both democrats and republicans are in the pockets of insurance companies.  It makes no difference who creates the health plan.  Both will continue to keep profits for those insurance companies while prices continue to rise.  But please lets keep yelling death panels and single payer until we are blue in the face.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #1851 on: April 06, 2017, 04:38:49 AM »
Single payer has the power to (1) ration care, and (2) set prices.  That's how the rest of the civilized world gets better health outcomes at half the cost.

That's simply not true as "the rest of the civilized world" does not uniformly have single payer systems.  This is a highly common piece of misinformation.  Germany and France, to name two large economies with world class systems, do not have single payer systems. 

ETA:  France was voted #1 in the world by the first and only WHO ranking.  And again, it's distinctly NOT single payer.  This piece of misinformation needs to be stopped.

If you follow the money, they function similar to single payer systems.  If most of the money ultimately comes from one source, that source is going to have a lot of power to regulate the system.

https://en.m.wikipedia.org/wiki/Healthcare_in_Germany

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According to the World Health Organization, Germany's health care system was 77% government-funded and 23% privately funded as of 2004.

http://www.expatica.com/fr/healthcare/french-healthcare-france-health-care-system_101166.html

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The French healthcare system covers both public and private hospitals, doctors and other medical specialists who provide French healthcare to every resident in France regardless of age, income or status. This makes the French health caresystem highly accessible, even for foreigners.
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Additionally, the majority of French healthcare costs are covered by the state via a public French healthcare insurance scheme. It is compulsory for residents in France to register with a French health insurer, as well as register with a doctor in France and go through this doctor for most treatments in order to be properly reimbursed by the French healthcare system.
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The healthcare system in France is funded partially by obligatory social security contributions (sécurité sociale), which are usually deducted from your salary. In 2016 employees paid around 8 percent in total, while employers paid around 13 percent of salary towards health costs. The French healthcare system is also partially funded by the government and the patient, too, pays a small contribution to their healthcare costs.
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When you see a doctor or have medical treatment a percentage of the cost – usually about 70 percent of doctors' fees and 80 percent of hospital costs – will be reimbursed for most people through the French healthcare system, so long as you are referred by your ‘attending doctor’ (see below). In the case of some major or long-term illnesses, 100 per cent of the costs are covered.

So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.
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PiobStache

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Re: What comes after the ACA?
« Reply #1852 on: April 06, 2017, 08:18:48 AM »
So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.

I'm glad my comment urged you to research and educate yourself, however, this comment misses the point.  A government doesn't need to fund something to control it; it simply legislates what it wants.  The basic philosophy of a Bismarck system is distinctly different than a single payer or a Beveridge (yes, there's even more modalities!) 

protostache

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Re: What comes after the ACA?
« Reply #1853 on: April 06, 2017, 12:19:41 PM »
So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.

I'm glad my comment urged you to research and educate yourself, however, this comment misses the point.  A government doesn't need to fund something to control it; it simply legislates what it wants.  The basic philosophy of a Bismarck system is distinctly different than a single payer or a Beveridge (yes, there's even more modalities!)

Here's a good overview of four of the main systems of providing healthcare in the world as of 2009.

bacchi

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Re: What comes after the ACA?
« Reply #1854 on: April 06, 2017, 01:08:37 PM »
Japan is another country that does not have single payer.

Did someone claim that it was? Well, they were wrong.

Japan does, however, have a nationalized price list. It also has an insurance mandate. Even more amazing -- people in Japan can get first-world treatment after hours (!).

Mr Mark

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Re: What comes after the ACA?
« Reply #1855 on: April 06, 2017, 02:15:47 PM »
So it's not so much the precise system but the obvious principle that all the country's citizens get basic health care? Wow.

But hey, USA USA no. 1 right?

Mr. Mark

sol

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Re: What comes after the ACA?
« Reply #1856 on: April 06, 2017, 03:34:40 PM »
The common theme in all of the most successful systems seems to be universal coverage, primarily paid for by taxes, with strong government oversight.

Funny that the republicans so violently oppose all three of those individually.  Imagine the heart attack they would have if we tried to have all three simultaneously.

Lagom

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Re: What comes after the ACA?
« Reply #1857 on: April 06, 2017, 04:04:58 PM »
So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.

I'm glad my comment urged you to research and educate yourself, however, this comment misses the point.  A government doesn't need to fund something to control it; it simply legislates what it wants.  The basic philosophy of a Bismarck system is distinctly different than a single payer or a Beveridge (yes, there's even more modalities!)

I'm struggling to see what you hope to accomplish with your posts other than being pedantic. Dems/the left chanting "single payer!" is pretty different from "death panel" BS because even if it reflects an ignorance of the various flavors of those sorts of health systems, as Sol mentioned, those systems still all share qualities that are implicit in the expectation of those "single payer" advocates.

In other words, we all know that those wanting a single payer system would almost universally be fine with a different structure that still accomplishes the same basic goals, so getting up in arms that they don't know the proper names for each of the options is somewhat pointless. That said, I do expect congressional representatives to be more nuanced in their policy-making, which they frequently aren't. But I think it's clear the "death panel" crew is still substantially more disingenuous and very obviously would oppose modeling ourselves after any of the countries mentioned.
« Last Edit: April 06, 2017, 05:38:01 PM by Lagom »

Monkey Uncle

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Re: What comes after the ACA?
« Reply #1858 on: April 06, 2017, 06:40:42 PM »
So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.

I'm glad my comment urged you to research and educate yourself, however, this comment misses the point.  A government doesn't need to fund something to control it; it simply legislates what it wants.  The basic philosophy of a Bismarck system is distinctly different than a single payer or a Beveridge (yes, there's even more modalities!)

Golly gee, do ya think ma uneducated lil self cud ever git as smart as you iz?

While you were busy splitting terminology hairs, I think you're the one who missed the point.  The successful health care systems around the world all feature universal coverage, paid for largely by a single source of funds (tax revenue).  The point is not that the Germans and Japanese set up a bunch of non-profit insurance entities to dispense the checks.  That feature is completely immaterial to the success of those systems in providing affordable, high quality, universally available health care.  The point is that the money ultimately comes from the government, as does the control over prices.  That is the real reason for those countries' health care success.
"Take this job and shove it" - David Allan Coe

marty998

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Re: What comes after the ACA?
« Reply #1859 on: April 07, 2017, 01:37:15 AM »
The common theme in all of the most successful systems seems to be universal coverage, primarily paid for by taxes, with strong government oversight.

Funny that the republicans so violently oppose all three of those individually.  Imagine the heart attack they would have if we tried to have all three simultaneously.

I suppose the cabinet members each have enough money to pay for all the surgery required following said heart attacks.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #1860 on: April 07, 2017, 07:37:14 AM »
So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.

I'm glad my comment urged you to research and educate yourself, however, this comment misses the point.  A government doesn't need to fund something to control it; it simply legislates what it wants.  The basic philosophy of a Bismarck system is distinctly different than a single payer or a Beveridge (yes, there's even more modalities!)

Golly gee, do ya think ma uneducated lil self cud ever git as smart as you iz?

While you were busy splitting terminology hairs, I think you're the one who missed the point.  The successful health care systems around the world all feature universal coverage, paid for largely by a single source of funds (tax revenue).  The point is not that the Germans and Japanese set up a bunch of non-profit insurance entities to dispense the checks.  That feature is completely immaterial to the success of those systems in providing affordable, high quality, universally available health care.  The point is that the money ultimately comes from the government, as does the control over prices.  That is the real reason for those countries' health care success.

I'm actually thankful that PiobStache commented the way he did, because the result was that you and Lagom articulated in an elegant manner the major themes of universal health coverage around the world.

Schaefer Light

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Re: What comes after the ACA?
« Reply #1861 on: April 07, 2017, 08:40:53 AM »
So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.

I'm glad my comment urged you to research and educate yourself, however, this comment misses the point.  A government doesn't need to fund something to control it; it simply legislates what it wants.  The basic philosophy of a Bismarck system is distinctly different than a single payer or a Beveridge (yes, there's even more modalities!)

Golly gee, do ya think ma uneducated lil self cud ever git as smart as you iz?

While you were busy splitting terminology hairs, I think you're the one who missed the point.  The successful health care systems around the world all feature universal coverage, paid for largely by a single source of funds (tax revenue).  The point is not that the Germans and Japanese set up a bunch of non-profit insurance entities to dispense the checks.  That feature is completely immaterial to the success of those systems in providing affordable, high quality, universally available health care.  The point is that the money ultimately comes from the government, as does the control over prices.  That is the real reason for those countries' health care success.

I'm actually thankful that PiobStache commented the way he did, because the result was that you and Lagom articulated in an elegant manner the major themes of universal health coverage around the world.

If one of those themes is higher taxes, then I don't want it.

bacchi

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Re: What comes after the ACA?
« Reply #1862 on: April 07, 2017, 08:47:44 AM »
I'm actually thankful that PiobStache commented the way he did, because the result was that you and Lagom articulated in an elegant manner the major themes of universal health coverage around the world.

If one of those themes is higher taxes, then I don't want it.

Considering how we currently pay much more vs other countries, the total bill would be less.

NoStacheOhio

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Re: What comes after the ACA?
« Reply #1863 on: April 07, 2017, 09:21:51 AM »
So essentially tax revenue in one form or another is covering the vast majority of costs.  Perhaps the systems aren't single-payer in name, but in reality they are.

I'm glad my comment urged you to research and educate yourself, however, this comment misses the point.  A government doesn't need to fund something to control it; it simply legislates what it wants.  The basic philosophy of a Bismarck system is distinctly different than a single payer or a Beveridge (yes, there's even more modalities!)

Golly gee, do ya think ma uneducated lil self cud ever git as smart as you iz?

While you were busy splitting terminology hairs, I think you're the one who missed the point.  The successful health care systems around the world all feature universal coverage, paid for largely by a single source of funds (tax revenue).  The point is not that the Germans and Japanese set up a bunch of non-profit insurance entities to dispense the checks.  That feature is completely immaterial to the success of those systems in providing affordable, high quality, universally available health care.  The point is that the money ultimately comes from the government, as does the control over prices.  That is the real reason for those countries' health care success.

I'm actually thankful that PiobStache commented the way he did, because the result was that you and Lagom articulated in an elegant manner the major themes of universal health coverage around the world.

If one of those themes is higher taxes premiums, then I don't want it.

FTFY. Now what?
The first step is acknowledging you have a problem, right?

https://forum.mrmoneymustache.com/journals/digging-out-of-a-hole/

PiobStache

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Re: What comes after the ACA?
« Reply #1864 on: April 07, 2017, 09:54:46 AM »

I'm struggling to see what you hope to accomplish with your posts other than being pedantic. Dems/the left chanting "single payer!" is pretty different from "death panel" BS because even if it reflects an ignorance of the various flavors of those sorts of health systems, as Sol mentioned, those systems still all share qualities that are implicit in the expectation of those "single payer" advocates.

In other words, we all know that those wanting a single payer system would almost universally be fine with a different structure that still accomplishes the same basic goals, so getting up in arms that they don't know the proper names for each of the options is somewhat pointless. That said, I do expect congressional representatives to be more nuanced in their policy-making, which they frequently aren't. But I think it's clear the "death panel" crew is still substantially more disingenuous and very obviously would oppose modeling ourselves after any of the countries mentioned.

Pointless?  If people believe the only choices are single payer or the current US status quo all we're going to get is either single player or the US status quo.  One can only chose between options one knows/understands.  To point out there are more options is not pedantic but rather an expansion of the choice universe and I fail to see how that is anything but a good thing.

I would have gone on to address universal but predictably the people I upset by pointing out their errors will try and shift the goal posts, ad hoc rescue...basically, whatever it takes not to just say, "Hey!  I was wrong.  Thanks for showing me more choices."  I'm all for a universal coverage system but I also am endlessly trying to educate Americans there's more choices out there.

Also, to thinking if a system is largely tax funded it is de facto "single payer."  Wrong.  "Single payer" means there's only one entity that people bill, i.e. the government.  Medicare, for example, is a single payer.  Folks can opt out of straight Medicare though, and take a Medicare Advantaged plan, and those folks don't participate in that single payer system as Medicare pays the insurance companies and the insurance companies become the payers.  It's an important difference as all those Medicare Advantaged plans differ from each other, i.e. consumer choice and product differentiation is offered.  That's a key thing in Bismarck systems, namely that within the floor set by the government, plans can be different from each other.

So apparently I'm a bad guy here/somehow wrong/a pedant for introducing some new facts.  Interesting.

Lagom

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Re: What comes after the ACA?
« Reply #1865 on: April 07, 2017, 10:14:05 AM »
Pointless?  If people believe the only choices are single payer or the current US status quo all we're going to get is either single player or the US status quo.  One can only chose between options one knows/understands.  To point out there are more options is not pedantic but rather an expansion of the choice universe and I fail to see how that is anything but a good thing.

I would have gone on to address universal but predictably the people I upset by pointing out their errors will try and shift the goal posts, ad hoc rescue...basically, whatever it takes not to just say, "Hey!  I was wrong.  Thanks for showing me more choices."  I'm all for a universal coverage system but I also am endlessly trying to educate Americans there's more choices out there.

Also, to thinking if a system is largely tax funded it is de facto "single payer."  Wrong.  "Single payer" means there's only one entity that people bill, i.e. the government.  Medicare, for example, is a single payer.  Folks can opt out of straight Medicare though, and take a Medicare Advantaged plan, and those folks don't participate in that single payer system as Medicare pays the insurance companies and the insurance companies become the payers.  It's an important difference as all those Medicare Advantaged plans differ from each other, i.e. consumer choice and product differentiation is offered.  That's a key thing in Bismarck systems, namely that within the floor set by the government, plans can be different from each other.

So apparently I'm a bad guy here/somehow wrong/a pedant for introducing some new facts.  Interesting.

Never called you a bad guy, just pedantic, which this post continues. If your goal was just to expand on options beyond "single payer" that still functionally accomplish what "single payer" supporters hope to see in our health system, you could have simply mentioned that there are alternatives that might be worth considering without complaining about how ignorant everyone supposedly is. Instead, you went off about how wrong all of the libs are to chant "single payer!" over and over in a manner that came across as smug and that implied you think their ideas are naive and have little merit.

You also claimed this was equivalent to the republican spin machine regarding the topic when you know very well that they would not support a system like Germany or Japan any more than they want us to emulate Scandinavia. Their spin has almost always been aimed at stopping such things (e.g. "death panels") rather than offering tenable alternatives.

PiobStache

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Re: What comes after the ACA?
« Reply #1866 on: April 07, 2017, 10:22:14 AM »
You're not reading the same thread I participated in as I never claimed anything as "equivalent."  You clearly have read quite a bit into what I've said.  Here's what I said:

Quote
Neither side is presenting a cogent, contextualized, rational position.  There's no "right side" in the US political system regarding healthcare at this moment.

If you feel this is incorrect, that's fine, but I made no statement as to who is more wrong than the other...just that neither side has is it right.

Also, could you quantify how many times "over and over" is for me?  I think you're upset at me as I did not beg people's pardon for being factually wrong and just want to fight with me.  That's cool but I'm not going to fight.  What I said was correct, what I responded to was incorrect, and again I'm a bad guy now for apparently not saying it in a way to soften the blow.


Never called you a bad guy, just pedantic, which this post continues. If your goal was just to expand on options beyond "single payer" that still functionally accomplish what "single payer" supporters hope to see in our health system, you could have simply mentioned that there are alternatives that might be worth considering without complaining about how ignorant everyone supposedly is. Instead, you went off about how wrong all of the libs are to chant "single payer!" over and over in a manner that came across as smug and that implied you think their ideas are naive and have little merit.

You also claimed this was equivalent to the republican spin machine regarding the topic when you know very well that they would not support a system like Germany or Japan any more than they want us to emulate Scandinavia. Their spin has almost always been aimed at stopping such things (e.g. "death panels") rather than offering tenable alternatives.

PiobStache

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Re: What comes after the ACA?
« Reply #1867 on: April 07, 2017, 10:28:37 AM »
Here's an idea:  instead of piling on me for whatever my transgressions are how about if we all agree Germany and France have great systems and start moving the national conversation that way?

Just a thought.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #1868 on: April 07, 2017, 10:45:23 AM »
Here's an idea:  instead of piling on me for whatever my transgressions are how about if we all agree Germany and France have great systems and start moving the national conversation that way?

Just a thought.

Yes !

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1869 on: April 07, 2017, 11:21:58 AM »
Considering how we currently pay much more vs other countries, the total bill would be less.

I'm curious to see if anyone has data regarding the percentage of population who suffer from lifestyle related illness in various countries. Anything related to metabolic syndrome as those diseases tend to cluster.  Addiction related disease drugs, alcohol, smoking, ect. I tend to be a believer that the payer/delivery system in the US is more expensive in large part because we lead shitty lifestyles that result in illness.  If this is the case, changing the way we pay or deliver our healthcare would be a positive step, but it wouldn't solve the underlying issues.  Arguments can be made that greater spending on education/awareness, preventative care could change the numbers and I would agree.  However, for now, are comparing apples to oranges regarding cost and quality? If we are comparing relatively healthy people (Japan/Europe) vs relatively sick people (USA), then its like comparing two distinct risk pools regarding cost and outcomes. 

PiobStache

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Re: What comes after the ACA?
« Reply #1870 on: April 07, 2017, 11:41:05 AM »
This is a really good question.  My reply is a bit tangential, but I just happen to have recently reviewed this study regarding emergency room utilization, and I often hear that if the US had Canadian style healthcare ED use would drastically drop but this does not seem to be the case.  I hope no one jumps on me for introducing this but here we go:  http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2007.02.030/pdf

Quote
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6)
per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population).

Kind of interesting, isn't it?


Considering how we currently pay much more vs other countries, the total bill would be less.

I'm curious to see if anyone has data regarding the percentage of population who suffer from lifestyle related illness in various countries. Anything related to metabolic syndrome as those diseases tend to cluster.  Addiction related disease drugs, alcohol, smoking, ect. I tend to be a believer that the payer/delivery system in the US is more expensive in large part because we lead shitty lifestyles that result in illness.  If this is the case, changing the way we pay or deliver our healthcare would be a positive step, but it wouldn't solve the underlying issues.  Arguments can be made that greater spending on education/awareness, preventative care could change the numbers and I would agree.  However, for now, are comparing apples to oranges regarding cost and quality? If we are comparing relatively healthy people (Japan/Europe) vs relatively sick people (USA), then its like comparing two distinct risk pools regarding cost and outcomes.

PathtoFIRE

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Re: What comes after the ACA?
« Reply #1871 on: April 07, 2017, 11:59:47 AM »
I'm curious to see if anyone has data regarding the percentage of population who suffer from lifestyle related illness in various countries. ...

I'm not at all current on what the bulk of research shows regarding this question. I do follow Tyler Cowen's Marginal Revolution blog though, I appreciate his contrarian views especially when I don't agree, and he linked to here a few days ago:
https://www.adamsmith.org/blog/us-healthcare-most-people-dont-know-what-theyre-talking-about

The argument made in this post (and I have no idea who the Adam Smith Institute is or where they lie on the political/economics spectrum though I have some guesses) is that it's accidents that skew life expectancy lower in the US compared to other developed countries, and that when you adjust those out, the US comes out on top, at least suggesting that maybe we actually do get slightly better actual healthcare outcomes for our mega-sized spending. I've also seen some other research (I can't seem to remember where) that basically shows that the US has always led on healthcare spending, and that other developed countries are lagging but keeping pace, again suggesting but not proving that the outsized spending in the US may not be quite as bad as it's made out.

Lagom

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Re: What comes after the ACA?
« Reply #1872 on: April 07, 2017, 12:18:20 PM »
Here's an idea:  instead of piling on me for whatever my transgressions are how about if we all agree Germany and France have great systems and start moving the national conversation that way?

Just a thought.

Yes !

Works for me. No piling on intended, just encouraging you to pump the breaks a bit :)

But agreed on all counts!

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1873 on: April 07, 2017, 12:28:58 PM »
Quote
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6)
per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population).

Kind of interesting, isn't it?
Yes it is.  I wonder what the average cost of an ER visit is in Canada vs US. I'm not talking out of pocket, but total actual cost. 

I still believe that prevention and education spending would provide great returns to our healthcare system overall, unless I found direct data to the contrary.

Take smoking for example.  The campaign has been an unequivocal win for public health and healthcare spending.  However, look what had to be done to manufacture this "win". Are we willing to run the same distance to combat obesity & metabolic syndrome?  Should state gov't sue Mcdonalds for advertising happy meals and providing playlands to children?  Should we substantially rasie taxes on all foods deemed to be contributors to the epidemic?  Should we ban eating bacon cheeseburgers in public?  Should we use funds from the mcdonalds law suits to pay for advertisements showing how gross and dirty obese people who eat bacon cheeseburgers are?  IDK, something about that makes my Gen X "nomad archetype" very uncomfortable.

The argument made in this post (and I have no idea who the Adam Smith Institute is or where they lie on the political/economics spectrum though I have some guesses) is that it's accidents that skew life expectancy lower in the US compared to other developed countries, and that when you adjust those out, the US comes out on top, at least suggesting that maybe we actually do get slightly better actual healthcare outcomes for our mega-sized spending. I've also seen some other research (I can't seem to remember where) that basically shows that the US has always led on healthcare spending, and that other developed countries are lagging but keeping pace, again suggesting but not proving that the outsized spending in the US may not be quite as bad as it's made out.
I'm sure it's a very fiscally right leaning source, but if the conclusions are accurate, I would have never guessed accidents/violent deaths in the US were so high vs other developed nations that they could skew the numbers to such a degree.

Gin1984

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Re: What comes after the ACA?
« Reply #1874 on: April 07, 2017, 01:22:22 PM »
Considering how we currently pay much more vs other countries, the total bill would be less.

I'm curious to see if anyone has data regarding the percentage of population who suffer from lifestyle related illness in various countries. Anything related to metabolic syndrome as those diseases tend to cluster.  Addiction related disease drugs, alcohol, smoking, ect. I tend to be a believer that the payer/delivery system in the US is more expensive in large part because we lead shitty lifestyles that result in illness.  If this is the case, changing the way we pay or deliver our healthcare would be a positive step, but it wouldn't solve the underlying issues.  Arguments can be made that greater spending on education/awareness, preventative care could change the numbers and I would agree.  However, for now, are comparing apples to oranges regarding cost and quality? If we are comparing relatively healthy people (Japan/Europe) vs relatively sick people (USA), then its like comparing two distinct risk pools regarding cost and outcomes.
Not exactly what you want but might lead to something:
http://www.pbs.org/newshour/rundown/report-americans-less-healthy-die-younger-than-global-peers/

PiobStache

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Re: What comes after the ACA?
« Reply #1875 on: April 07, 2017, 02:06:45 PM »
I still believe that prevention and education spending would provide great returns to our healthcare system overall, unless I found direct data to the contrary.

I'm big on education and prevention too.  During my field work in grad school one of the things I did was participate in an HTN education study.  The setting was a community health clinic in the inner city of a large Rust Belt city.  For a week, if a patient was diagnosed with HTN, they would meet me with or another grad student to be educated about the causes and risks of hypertension.  There was a 20 question, multiple choice post-test, and the final question was, "Do you have hypertension or high blood pressure?"  Eighty percent answered in the negative.

The main thing isn't education but overcoming our highly developed ability to not deal with negative health issues.

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1876 on: April 07, 2017, 02:21:23 PM »
The main thing isn't education but overcoming our highly developed ability to not deal with negative health issues.

Yes, I work in healthcare and have seen some "ahha" moments when providing education, but you are right, it has to be something people want to do.  That requires changing culture to the degree that the smoking cession example did.

Not exactly what you want but might lead to something:
http://www.pbs.org/newshour/rundown/report-americans-less-healthy-die-younger-than-global-peers/
@Gin1984 thanks!  That info pretty much supports the argument that the US spends more for less results.  What I am wondering (and will try to find when I have more free time) is something like this:

Japan spends $x in treating diabetes with a similar population to the US.  The US spends 3($x) in treating diabetes and the average diabetic lives one year less in the US.  This looks pretty shitty on the surface... but...  What if y% of japans 40+ population have diabetes, but in the US that number is 5(y%) of 40+ population.  Suddenly the health care expenditure picture changes, no?  Hence my analogy to a totally different risk pool.  I don't know if this is true, but that's the data I'm interested in.

Gin1984

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Re: What comes after the ACA?
« Reply #1877 on: April 07, 2017, 02:28:33 PM »
The main thing isn't education but overcoming our highly developed ability to not deal with negative health issues.

Yes, I work in healthcare and have seen some "ahha" moments when providing education, but you are right, it has to be something people want to do.  That requires changing culture to the degree that the smoking cession example did.

Not exactly what you want but might lead to something:
http://www.pbs.org/newshour/rundown/report-americans-less-healthy-die-younger-than-global-peers/
@Gin1984 thanks!  That info pretty much supports the argument that the US spends more for less results.  What I am wondering (and will try to find when I have more free time) is something like this:

Japan spends $x in treating diabetes with a similar population to the US.  The US spends 3($x) in treating diabetes and the average diabetic lives one year less in the US.  This looks pretty shitty on the surface... but...  What if y% of japans 40+ population have diabetes, but in the US that number is 5(y%) of 40+ population.  Suddenly the health care expenditure picture changes, no?  Hence my analogy to a totally different risk pool.  I don't know if this is true, but that's the data I'm interested in.
The problem I see with finding that data is that early treatment has such an effect.  For example, my grandmother was discovered to have diabetes at age 19, with her first child. She only needed to be on insulin for the first few years because she was able to control it via diet.  But had to been discovered much later it may not have been possible to treat it in same way.  And if she had check ups as a child, it may have been discovered and treated even earlier with even less effect on her health. 
I don't know how to compare health vs unhealthy when the healthy group has preventative care and the other does not. 

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Re: What comes after the ACA?
« Reply #1878 on: April 07, 2017, 02:35:01 PM »
<snip> Should state gov't sue Mcdonalds for advertising happy meals and providing playlands to children?  Should we substantially rasie taxes on all foods deemed to be contributors to the epidemic?  Should we ban eating bacon cheeseburgers in public?  Should we use funds from the mcdonalds law suits to pay for advertisements showing how gross and dirty obese people who eat bacon cheeseburgers are?  <snip>
I don't understand people's obsession with blaming McDonald's.

We sit too much and all food, even home cooked food, is too convenient. 

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1879 on: April 07, 2017, 02:37:39 PM »
@ Gin1984, agreed that this data may not exist in the form I would like.  Additionally, even more difficult to tell on which form of treatment the money was spent, or was it spent on prevention. 

My general point is, shouldn't our efforts be partly focused on why US citizens are so unhealthy compared to our developed peers (if that is the case).  As opposed to only throwing a bunch of money and intellectual effort around to determine which delivery system is most effective.  Improve delivery to provide access.  Make US citizens less unhealthy to reduced total costs.   It seems the two issues are intertwined and need to be addressed as a whole.  Does one naturally lead to the other? 

EDIT: agree with @ geekette, I was just trying to provide a prominent example.
« Last Edit: April 07, 2017, 02:39:12 PM by Classical_Liberal »

PiobStache

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Re: What comes after the ACA?
« Reply #1880 on: April 07, 2017, 02:44:42 PM »
The OECD always has great data to look at.  Look at the graph at the end of this report:

http://www.oecd.org/health/49716427.pdf

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Re: What comes after the ACA?
« Reply #1881 on: April 07, 2017, 06:43:44 PM »
Here's an idea:  instead of piling on me for whatever my transgressions are how about if we all agree Germany and France have great systems and start moving the national conversation that way?

Just a thought.

Well, I think we can agree on that point. 

But surely you can see that the reason for the piling on was your waving around of superficial details in an attempt to demonstrate your encyclopedic knowledge on the subject.  Instead of impressing everyone with your intellectual superiority, you came across as a petty nitpicker who knows all the meaningless trivia but is oblivious to the real subject of the discussion.

By the way, your posts after the quoted one above were quite constructive.  Glad to see those.
« Last Edit: April 07, 2017, 06:49:03 PM by Monkey Uncle »
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obstinate

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Re: What comes after the ACA?
« Reply #1882 on: April 08, 2017, 08:14:20 PM »
Maybe if some more republicans go on TV and shout about DEATH PANELS often enough, that will clear things up for everybody.

Or if more Dems keep chanting, "Single payer!  Single payer!"
Single payer is cogent, contextualized, and rationalized. It actually exists in many other countries. It is totally distinct from the anti-factual claim that Obamacare involved "death panels."

Monkey Uncle

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Re: What comes after the ACA?
« Reply #1883 on: April 09, 2017, 04:48:28 AM »
Interesting article that suggests the ACA markets would be o.k., if only the republicans would stop trying to actively sabotage them:

http://www.msn.com/en-us/news/us/insurers-stem-losses-and-may-soon-profit-from-obamacare-plans/ar-BBzy9kg

Quote
The analysis, by Standard & Poor’s, looked at the performance of many Blue Cross plans in nearly three dozen states since President Barack Obama’s health care law took effect three years ago. It shows the insurers significantly reduced their losses last year, are likely to break even this year and that most could profit — albeit some in the single-digits — in 2018. The insurers cover more than five million people in the individual market.

After years in which many insurers lost money, then lost even more in 2015, “we are seeing the first signs in 2016 that this market could be manageable for most health insurers,” the Standard & Poor’s analysts said. The “market is not in a ‘death spiral,’ ” they said.

Quote
It is the latest evidence that the existing law has not crippled the market where individuals can buy health coverage, although several insurers have pulled out of some markets including two in Iowa just this week. They and other industry specialists have cited the uncertainty surrounding the Congressional debate over the law, and the failed effort two weeks ago by House Republicans to bring a bill to the floor for a vote.

The bad part is that they are achieving stability by raising prices and narrowing coverage networks:

Quote
While it took longer than expected, the insurers appear to be starting to understand how the new individual market works, said Deep Banerjee, an S.&P. credit analyst who helped write the report. The companies have aggressively increased their prices, so they are now largely covering their medical costs, Mr. Banerjee said. They have also significantly narrowed their networks to include fewer doctors and hospitals as a way to lower those costs.

While most customers don't see those increased costs due to subsidies, this fact shows that as a society we still need to deal with the real underlying problem, which is out-of-control costs.  Personally, I think that if we could stabilize and grow the ACA networks such that the government is paying for most of the country's health care (between ACA, Medicare, and expanded Medicaid), that could generate some of the market leverage that is needed to start bending the cost curve down.  IMHO, one of the best reforms Congress could take toward this end would be to eliminate the ACA mandate that employers over a certain size provide health insurance.  That ought to grow the ACA networks nicely, and it would diversify the customer base beyond the sick-heavy population that the networks currently cover.

But of course, it's a pipe dream to think that the current Congress would do anything that would help stabilize the ACA networks.


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EnjoyIt

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Re: What comes after the ACA?
« Reply #1884 on: April 09, 2017, 06:47:03 PM »
Don't we have a single payer system for the 65 and over and the poor?  I do not see it controlling costs.  On the contrary, I keep seeing costs rise.  It looks to be 24% of US spending and rising.  I do not see single payer working very well in this country.


obstinate

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Re: What comes after the ACA?
« Reply #1885 on: April 09, 2017, 08:38:20 PM »
Don't we have a single payer system for the 65 and over and the poor?  I do not see it controlling costs.  On the contrary, I keep seeing costs rise.  It looks to be 24% of US spending and rising.  I do not see single payer working very well in this country.


Single payer for a fraction of the population cannot be expected to control costs for the entire population. That is silly. Medicaid has very good cost characteristics compared to private insurance.

EnjoyIt

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Re: What comes after the ACA?
« Reply #1886 on: April 09, 2017, 11:00:38 PM »
Medicaid/Medicaid manages the care for a very large portion of the US population. 114 million to be close to exact. That is about 35% of the population. Why can't it control costs? Even in countries with socialized medicine, those who can afford it opt for a private option yet they are able to control costs. Why can't the US?
« Last Edit: April 09, 2017, 11:04:39 PM by EnjoyIt »

sol

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Re: What comes after the ACA?
« Reply #1887 on: April 09, 2017, 11:14:33 PM »
Medicaid/Medicaid manages the care for a very large portion of the US population. Why can't it control costs? Even in countries with socialized medicine, those who can afford it opt for a private option yet they are able to control costs. Why can't the US?

I feel like these must be rhetorical questions, because the answers seem obvious to me. 

But just in case you're serious, I'll spell it out.  Medicaid and Medicare have fixed prices lists for procedures that only apply to people using those programs, and as such are effective at controlling costs for those patients.  But since other people don't use those programs, and providers are allowed to charge whatever outrageous price gouging they want to (we call that a "free market"), private insurance ends up paying more.  American providers are allowed to completely ignore the fixed prices list, and they are allowed to turn away patients who pay using government health insurance.

In other countries with "socialized medicine" the government has the oversight authority to regulate health care providers, to prevent things like price gouging or pushing expensive and unnecessary care or ineffective treatments that don't improve outcomes.  Every provider has to meet the government's minimum standards, and accept the government's profit structure (and sometimes they also get a government guarantee (i.e. bailout) if that profit structure turns out to be insufficient).  Providers cannot refuse to accept medicaid patients because just because they prefer to price gouge private insurance.  Citizens can still buy private insurance, but it is in ADDITION TO their government-provided benefits, not a replacement plan.  Private insurance may cover more services, or allow access to other providers the government doesn't (e.g. crystal healing of your chakras, chiropracters, fancier recovery rooms) but that doesn't change the price for the basic services covered by the government.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #1888 on: April 10, 2017, 04:17:26 AM »
Yes, this. ^^^

And also, don't forget that Medicare is legally prohibited from negotiating prescription drug prices.  Because Congress loves the free market, except when it gets in the way of their patrons' price gouging.
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Classical_Liberal

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Re: What comes after the ACA?
« Reply #1889 on: April 10, 2017, 04:23:51 AM »
Medicaid/Medicaid manages the care for a very large portion of the US population. Why can't it control costs? Even in countries with socialized medicine, those who can afford it opt for a private option yet they are able to control costs. Why can't the US?

I feel like these must be rhetorical questions, because the answers seem obvious to me. 

But just in case you're serious, I'll spell it out.  Medicaid and Medicare have fixed prices lists for procedures that only apply to people using those programs, and as such are effective at controlling costs for those patients.  But since other people don't use those programs, and providers are allowed to charge whatever outrageous price gouging they want to (we call that a "free market"), private insurance ends up paying more.  American providers are allowed to completely ignore the fixed prices list, and they are allowed to turn away patients who pay using government health insurance.

In other countries with "socialized medicine" the government has the oversight authority to regulate health care providers, to prevent things like price gouging or pushing expensive and unnecessary care or ineffective treatments that don't improve outcomes.  Every provider has to meet the government's minimum standards, and accept the government's profit structure (and sometimes they also get a government guarantee (i.e. bailout) if that profit structure turns out to be insufficient).  Providers cannot refuse to accept medicaid patients because just because they prefer to price gouge private insurance.  Citizens can still buy private insurance, but it is in ADDITION TO their government-provided benefits, not a replacement plan.  Private insurance may cover more services, or allow access to other providers the government doesn't (e.g. crystal healing of your chakras, chiropracters, fancier recovery rooms) but that doesn't change the price for the basic services covered by the government.

Just so you are aware, the term "providers" in medical speak means doctors, NP's, PA's, ect.  When you rattle on about price gouging by "providers", it come across to anyone in the medical field you are insinuating that "providers" are setting prices for the services.  Of course, in reality, providers have very little control over who (ins/medicare/medicaid) and how much is being billed to the patients.  With the exception of private practices which are very few and far between.

Since I sincerely respect your opinions and contributions on this forum; I'll give you the benefit of the doubt and assume when you say "providers" you mean the ubiquitous evil hospital or insurance company, ect.  If I'm wrong on what you "mean", feel free to correct me. However, if that's case you don't understand the nuts & bolts of our healthcare system at all.

As far as medicare dictating prices through DRG"s, I would completely agree.  Also would agree a single payer would have more power to do so & this would be a good thing in this country.

Roland of Gilead

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Re: What comes after the ACA?
« Reply #1890 on: April 10, 2017, 08:45:41 AM »
While we are talking about other countries and what they do, we should note that other countries have much more limitations on how you can sue a doctor, hospital or drug company.   That lowers the cost of doing business but doesn't seem to be something the American people want to give up (their ability to make a mega payday if a loved one dies due to a hospital error or drug side effect).

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Re: What comes after the ACA?
« Reply #1891 on: April 10, 2017, 09:06:29 AM »
Don't we have a single payer system for the 65 and over and the poor?  I do not see it controlling costs.  On the contrary, I keep seeing costs rise.  It looks to be 24% of US spending and rising.  I do not see single payer working very well in this country.[/img]

Medicare does a better job of controlling costs than the private sector. It's expensive because it serves an expensive group of people (old people).

http://www.consumerwatchdog.org/blog/private-insurance-vs-medicare-truth-numbers

sol

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Re: What comes after the ACA?
« Reply #1892 on: April 10, 2017, 10:10:53 AM »
the term "providers" in medical speak means doctors, NP's, PA's, ect.  When you rattle on about price gouging by "providers", it come across to anyone in the medical field you are insinuating that "providers" are setting prices for the services. 

I intended the word "providers" to mean the organizations that profit by providing more care than is necessary, as distinct from the insurers that just act as middle men.  I recognize that individual workers do not set these prices, but it is also important to remember that they do benefit from them, and are thus unwittingly complicit.  When your hospital network administrators negotiate an inflated rate with the insurers network, they are price fixing for the purpose of paying themselves and their employees, at the expense of people who buy insurance.  I don't blame the nurse for this, since she is just doing a job.  I sometimes blame the doctors who willingly order extra tests because they know how to generate extra profit.

I work (as a lowly cog) for the executive branch of the federal government.  I am thus also complicit in the actions of our chief executive, though I have absolutely no influence on the policies he sets.  I'm still part of the system responsible.   
« Last Edit: April 10, 2017, 10:40:24 AM by sol »

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1893 on: April 10, 2017, 10:36:25 AM »
the term "providers" in medical speak means doctors, NP's, PA's, ect.  When you rattle on about price gouging by "providers", it come across to anyone in the medical field you are insinuating that "providers" are setting prices for the services. 

I intended the word "providers" to mean the organizations that profit by providing more care than is necessary, as distinct from the insurers that just act as middle men.  I recognize that individual workers do not set these prices, but it is also important to remember that they do benefit from them, and are thus unwittingly complicit.  When your hospital network administrators negotiate an inflated rate with the insurers network, they are price fixing for the purpose of paying themselves and their employees, at the expense of people who buy insurance.  I don't blame the nurse for this, since she is just doing a job.  I sometimes blame the doctors who willingly order extra tests because they know how to generate extra profit.

I work for the executive branch of the federal government.  I am thus also complicit in the actions of our chief executive, though I have absolutely no influence on the policies he sets.  I'm still part of the system responsible.   

I would agree with this statement in it's entirety.  Except to point out many providers willingly order extra tests to avoid liability.  In these cases, the tort system may be partially responsible.

bacchi

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Re: What comes after the ACA?
« Reply #1894 on: April 10, 2017, 10:43:48 AM »
the term "providers" in medical speak means doctors, NP's, PA's, ect.  When you rattle on about price gouging by "providers", it come across to anyone in the medical field you are insinuating that "providers" are setting prices for the services. 

I intended the word "providers" to mean the organizations that profit by providing more care than is necessary, as distinct from the insurers that just act as middle men.  I recognize that individual workers do not set these prices, but it is also important to remember that they do benefit from them, and are thus unwittingly complicit.  When your hospital network administrators negotiate an inflated rate with the insurers network, they are price fixing for the purpose of paying themselves and their employees, at the expense of people who buy insurance.  I don't blame the nurse for this, since she is just doing a job.  I sometimes blame the doctors who willingly order extra tests because they know how to generate extra profit.

I work for the executive branch of the federal government.  I am thus also complicit in the actions of our chief executive, though I have absolutely no influence on the policies he sets.  I'm still part of the system responsible.   

I would agree with this statement in it's entirety.  Except to point out many providers willingly order extra tests to avoid liability.  In these cases, the tort system may be partially responsible.

That reminds me of this article.

http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum

tl; dr Doctors in the Texas Valley significantly over test even with one of the strongest anti-malpractice laws in the nation.

sol

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Re: What comes after the ACA?
« Reply #1895 on: April 10, 2017, 10:55:04 AM »
Sure, there are dual incentives.  Why would a doc NOT order extra testing, when it just might catch something incredibly rare, and also makes him a whole bunch of money?

I face this same dilemma as a scientist.  Do I order the entire suite of analytes even though I expect most of them to be zero, on the off chance there is something weird going on in some samples?  Do I charge my customer for this additional work, and thus pay my people to do extra lab work while I skim off the extra overhead costs bundled with the cost of the extra testing?  More information is better, even when that information is a negative finding.  It's a tough decision even for me, and I'm not usually dealing with people's lives.  But if I think I'm going to have to testify about my results, you'd better believe I pay to be rock solid about my data integrity.

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1896 on: April 10, 2017, 07:40:41 PM »
...and I'm not usually dealing with people's lives.

This is the key to your statement.  Providers are always dealing with peoples lives. How much is too much, even if it's pnly a near zero chance of diagnosis. 


That reminds me of this article.

http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum

tl; dr Doctors in the Texas Valley significantly over test even with one of the strongest anti-malpractice laws in the nation.

Interesting article, makes one wonder wonder how much of this is a training/education situation for doctors.  As far as the examples, it hits the nail on the head of one type of what I see all too often.  Sometimes the specialist referrals are like rabbit holes.  Procedures to test to make sure you can have procedures, medication to help with side effects of medications. Personally, I know better than to start with that game, but most do not. However, I stand by my assertion that it is rare to find a provider who suggests a procedure for the purpose of personal gain. Most really want to do what is best for the patient, although their training sometimes misguides.

EnjoyIt

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Re: What comes after the ACA?
« Reply #1897 on: April 11, 2017, 05:19:19 AM »
Medicaid/Medicaid manages the care for a very large portion of the US population. Why can't it control costs? Even in countries with socialized medicine, those who can afford it opt for a private option yet they are able to control costs. Why can't the US?

I feel like these must be rhetorical questions, because the answers seem obvious to me. 

But just in case you're serious, I'll spell it out.  Medicaid and Medicare have fixed prices lists for procedures that only apply to people using those programs, and as such are effective at controlling costs for those patients.  But since other people don't use those programs, and providers are allowed to charge whatever outrageous price gouging they want to (we call that a "free market"), private insurance ends up paying more.  American providers are allowed to completely ignore the fixed prices list, and they are allowed to turn away patients who pay using government health insurance.

In other countries with "socialized medicine" the government has the oversight authority to regulate health care providers, to prevent things like price gouging or pushing expensive and unnecessary care or ineffective treatments that don't improve outcomes.  Every provider has to meet the government's minimum standards, and accept the government's profit structure (and sometimes they also get a government guarantee (i.e. bailout) if that profit structure turns out to be insufficient).  Providers cannot refuse to accept medicaid patients because just because they prefer to price gouge private insurance.  Citizens can still buy private insurance, but it is in ADDITION TO their government-provided benefits, not a replacement plan.  Private insurance may cover more services, or allow access to other providers the government doesn't (e.g. crystal healing of your chakras, chiropracters, fancier recovery rooms) but that doesn't change the price for the basic services covered by the government.

The question is not rhetorical. Let's just look at the single payer government program Medicare and Medicaid they have full control and indeed set prices. Every year there is a meeting called the RUC that sets all reimbursement for all CPT codes (billing codes). It is the same reimbursement that private insurance companies follow and set their rates. They usually claim reimbursement as a percent of Medicare. Either way the government has full control over how much they are willing to pay and control costs yet the cost of health care continues to rise for the government and currently a huge percent of the federal government budget. It appears to me this single payer system is failing in the US.

I have explained why it is failing in many many previous posts. until those items are fixed it makes no difference who the payer is, costs will continue to rise.

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Re: What comes after the ACA?
« Reply #1898 on: April 11, 2017, 09:08:56 AM »
I would agree with this statement in it's entirety.  Except to point out many providers willingly order extra tests to avoid liability.  In these cases, the tort system may be partially responsible.

I'm a pathologist, and while I'm in a narrow field and don't see the breadth of test ordering, I can say for certainty seeing the ordering behaviors of my particular niche of associated clinicians (what we pathologists call doctors who see the actual patients) that it is a very rare clinician who over-orders testing in order to generate income (I can think of only one). Instead it is mostly ignorance of what is actually appropriate for a given situation, maybe combined with a little fear of missing something. And when I say what's appropriate, I see both testing ordered that is not appropriate, as well as testing not ordered that should be. Medicine is still very much the wild west when it comes to individual practice, and so much bad behavior (of the overtesting financial sort) can be waved away with so-called community standards. We are starting to see standardization of diagnosis and treatment in the cancer realm, I can't speak to other areas of medicine, but I think creation and enforcement of standards based on evidence is what will truly curb unnecessary testing/treatment more so than the constant whittling away of reimbursement that CMS, followed by the commercial carriers, has used as their primary tool to curb costs for the past few decades.

PiobStache

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Re: What comes after the ACA?
« Reply #1899 on: April 11, 2017, 10:28:42 AM »
Here's an idea:  instead of piling on me for whatever my transgressions are how about if we all agree Germany and France have great systems and start moving the national conversation that way?

Just a thought.

Well, I think we can agree on that point. 

But surely you can see that the reason for the piling on was your waving around of superficial details in an attempt to demonstrate your encyclopedic knowledge on the subject.  Instead of impressing everyone with your intellectual superiority, you came across as a petty nitpicker who knows all the meaningless trivia but is oblivious to the real subject of the discussion.

By the way, your posts after the quoted one above were quite constructive.  Glad to see those.

They are not superficial nor meaningless trivia.  Paradigms are highly important particularly in public policy.  As to intellectual superiority...well, I'm sort of slow so nothing to worry about there.