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Learning, Sharing, and Teaching => Ask a Mustachian => Topic started by: TheDudeReturns on July 05, 2015, 12:21:18 AM

Title: Obamacare Blues: But I don't want Medicaid...
Post by: TheDudeReturns on July 05, 2015, 12:21:18 AM
Okay, looking at some options, and Obamacare is confusing the hell out of me.

I keep seeing that below a certain MAGI, you are *INELIGIBLE* for the tax credits on Healthcare.gov and they tell you to get Medicaid. Sure, you are free to get a plan and pay 100% out of pocket, but I'm looking at the plans and they're more than my mortgage on a monthly basis. Nice that we completely got rid of the $50 a month catastrophe plans I saw a few years ago. You know, the ones that actually operated as insurance and were pretty cheap...

So, aside from keeping myself cushioned in bubblewrap in my bubble-boy ball and hoping to never go to the hospital, is there are way to pay for a plan and get the tax credits/subsidies? Let's try some scenarios:

(1) Income below the MAGI cutoff, but put in higher income at sign-up, pay the extra, and get some back at tax time
(2) Income above MAGI cutoff, but falls over the year, and MAGI at tax time is in Medicaid territory

I'm sure there are others, but these 2 come to mind. I guess if you put in a higher income and then get back extra, then can force you to repay them since you didn't get enrolled in Medicaid and you're forced to do so for the future?

Honestly, it seems if you're around the cutoff, you are screwed. You are either forced to get crappy Medicaid and have no one in a 100 mile radius take you as a patient, or you have the benefit of paying $359 monthly ($4308 yearly) for junk catastrophe plan. Sorry, but add $50 more a month and I can double my mortgage payments thanks.

Thanks to those who can shed light on this topic :)
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MDM on July 05, 2015, 12:34:28 AM
There are a bunch of links at http://forum.mrmoneymustache.com/ask-a-mustachian/information-on-the-affordable-care-act-with-a-focus-on-early-retirees/.

As noted in that thread, you are doing the right thing by posting your specific question in your own thread.  It might be worthwhile, however, to check there for possible answers.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: amberfocus on July 05, 2015, 12:47:34 AM
The simplest way to push your MAGI above 138% FPL and stay off Medicaid is to do Roth conversions. Is that not an option for you?
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on July 05, 2015, 06:21:10 AM
Medicaid is a state-based plan, so the details vary by state. However, in general, outcomes for people on Medicaid are about the same for people on private insurance, when adjusting for the health of the people prior to enrolling. Translation: Medicaid is great coverage.

And about 75% of all people on Medicaid around the country are actually enrolled in private insurance--it's called Medicaid managed care. The state is just paying a private insurer to take care of all your healthcare needs. Translation: Medicaid is actually private insurance for 75% of enrollees--and that number is growing rapidly.

But you can increase your income to 138% of FPL and just get a private plan. There are many ways to do that, including IRA conversions, earning a little money on the side and reporting it, taking fewer pre-AGI write-offs, etc.

Also, those pre-ACA catastrophic coverage plans you mention weren't really so great. They were generally only available to healthy people with no pre-existing conditions, or with exclusions for any care related to that pre-existing condition. They also had the ability to drop you from coverage if you got sick (so it really wasn't insurance) and they had caps for how much they would pay out in a year or cumulatively over your lifetime (so it really wasn't full insurance). And any plan is going to cost more now because of medical cost inflation. That's just a fact of economics. Hopefully we can some day adopt a system in this country that actually cuts out all that waste in the industry (most of which is in the private sector). Until then, this is what we've got.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Another Reader on July 05, 2015, 06:38:31 AM
"Medicaid is great coverage."

I hope you get the chance to be covered by Medicaid someday.  Same outcomes?  Maybe, for the few people that get to see a doctor.  Medicaid in California, called Medi-Cal, is pretty much the same as no health insurance.  Few doctors take it, even fewer specialists. 

Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Roland of Gilead on July 05, 2015, 06:50:01 AM
I am not seeing the difference between your $50 catastrophic plan and you going on Medicaid...except that you actually save $50 a month.

Your $50 plan would pay zilch for most things you would actually go to the doctor for....it might kick in when you have a $40,000 procedure.

Can you just pay your bills out of pocket like you would have with the $50 plan while you are on Medicaid?  I guess most doctors who don't accept Medicaid do accept cash?

It is really pretty easy to get your income up to $12,000 a year or whatever for a super subsidized silver plan with cheese.   You could do the opposite of tax loss harvesting and harvest only the gainers in your portfolio.  You can do IRA to Roth conversions.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on July 05, 2015, 07:12:07 AM
"Medicaid is great coverage."

I hope you get the chance to be covered by Medicaid someday.  Same outcomes?  Maybe, for the few people that get to see a doctor.  Medicaid in California, called Medi-Cal, is pretty much the same as no health insurance.  Few doctors take it, even fewer specialists. 

Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

I have been on Medi-Cal before actually. I'd be fine going back on Medicaid again if needed.

I mentioned that the situation varies by state. Medi-Cal is going through some huge growing pains because they just had about 3.2 million new enrollees in just over a year. That's a 35% increase. That's too much growth to digest quickly. And California has the 3rd-lowest Medicaid reimbursement rate in the nation, so it is harder to get doctors to participate there. The situation will get better in the state, but it will take some time. Their budget process is really difficult to fix quickly due to needing 2/3 of both chambers to approve any budget.

There is a lot of research that shows similar outcomes for Medicaid vs private insurance, adjusted for health prior to entering the system. There is also research showing that people have improved outcomes after getting Medicaid from being uninsured.

And things are very different in other states. Surveys of doctors are showing that around the nation providers were taking new Medicaid patients at a higher rate than in prior years.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: startingsmall on July 05, 2015, 07:17:38 AM
My mom was put on Medicaid when she was diagnosed with lung cancer ~ 10 years ago and stayed on it until she passed away about 5 years later.  I was amazed at the excellent quality of care that she received... despite the fact that she was an incredibly non-compliant patient and very difficult to deal with.  Multiple surgeries, chemo, radiation, you name it... and never any significant delays in care.  The ONLY complaint she had was that she had to go to a nursing home for rehab at one point and her options there were limited.  The rest of her care, though, was spectacular - minimal waits, all of her specialists were conveniently located in her town, etc.  This was in Florida, so again it may vary by state.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: wenchsenior on July 05, 2015, 08:18:08 AM
My mom was put on Medicaid when she was diagnosed with lung cancer ~ 10 years ago and stayed on it until she passed away about 5 years later.  I was amazed at the excellent quality of care that she received... despite the fact that she was an incredibly non-compliant patient and very difficult to deal with.  Multiple surgeries, chemo, radiation, you name it... and never any significant delays in care.  The ONLY complaint she had was that she had to go to a nursing home for rehab at one point and her options there were limited.  The rest of her care, though, was spectacular - minimal waits, all of her specialists were conveniently located in her town, etc.  This was in Florida, so again it may vary by state.

Medicaid in WI (which I was familiar with until a few years ago) was also excellent. It really is a state-by-state situation.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on July 05, 2015, 08:24:28 AM
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Bracken_Joy on July 05, 2015, 09:01:17 AM
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.

+1. As someone who has been on both sides- I've been on Oregon Health Plan (OR's medicaid) and as a healthcare worker, it's a good plan. They put you in managed care networks and while the "HMO feel" gets a bad rap, it makes it easier to navigate in a lot of ways to be totally honest... I don't have to worry about someone saying they take my insurance, and then my insurance refusing to pay, etc. At least not that I ever experienced. And that happened several times with my previous insurance(s). 

I will say it's less ideal when you're in a very rural area. If your area has one General Practitioner, and they don't take your care network... well. That sucks. But then, that's why OR is increasing nurse practitioner roles.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on July 05, 2015, 09:17:29 AM
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.

Even in Calif it's not all bad as I think it highly depends on your county. Here in Orange County you have a choice of several different private policies where you can pick from a wide range of doctors in pretty much every specialty, hospitals and medical clinics in the area (100's of choices). I think it's called Opticare or something like that.

That's another good point. CA is really several huge markets, so there is even significant intra-state variation. Even private insurers specialize in one region or another. Since Medicaid is a state-based program, states organize things differently. I don't recall if CA parcels it out to the counties to implement, but that would fit with their other public health practices.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Axecleaver on July 06, 2015, 10:51:56 AM
Quote
(1) Income below the MAGI cutoff, but put in higher income at sign-up, pay the extra, and get some back at tax time
(2) Income above MAGI cutoff, but falls over the year, and MAGI at tax time is in Medicaid territory

I wanted to respond to OP's questions.
1. Lie about your income. No, this won't work. During signup there are required documentation checks. In the state systems I've worked on, including the federal exchange, the system will check your tax return, and if this doesn't match (within a certain tolerance) what you enter, you'll be required to send in proof of income (pay stubs). So, don't try to lie about your income, it won't work.

2. Variable income which ends up in Medicaid territory after estimating it above 138%. This is somewhat complex, but a fairly common scenario as many low-income folks have extremely variable incomes. You may end up paying penalties depending on how this is calculated. There are IRS rules for how to do this, but I haven't gotten into them very deeply.

That said - Medicaid is an extremely high quality plan that pays for things private insurance doesn't (dental, taxi rides to the doctor, preventive care); I'd love to have Medicaid insurance. If you have problems with provider coverage, you can call the Medicaid agency and they will work with you to find providers that will take your insurance. Some specialties have very thin networks, but that's true in lots of areas of the country and for private plans, too. Most psychiatrists don't take insurance of any kind.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: catccc on July 06, 2015, 12:31:55 PM
Medicaid is a state-based plan, so the details vary by state. However, in general, outcomes for people on Medicaid are about the same for people on private insurance, when adjusting for the health of the people prior to enrolling. Translation: Medicaid is great coverage.

So I see many noting that this depends on the state.  I can say when DD was on medicaid as an infant it was great.  I didn't feel limited at all in who provided her care.  I'm in PA.  I would have loved to have qualified for it myself but I did not.  So I carried a low cost indemnity plan for a stretch of time.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 18, 2015, 06:23:36 PM
I did some research today and for the Medicaid expansion states, I think all but 2 or 3 (AR and CT were ones I could identify) are using private insurance to fulfill the coverage. So if you get "Medicaid" through the expansion, you are probably just getting private insurance that the state contracts with the private insurer to provide to beneficiaries. And anecdotally, the private insurers pay the providers more than the state FFS Medicaid program does, so providers take this Medicaid more readily. In fact, the state contracts with the insurer requires the insurer to ensure that there are sufficient providers available in each area of the state. So access to doctors and hospitals should typically not be a problem for Medicaid beneficiaries going forward.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: EscapeVelocity2020 on August 18, 2015, 06:26:33 PM
What is your age, are you eligible for Medicare yet?
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 18, 2015, 07:11:00 PM
I did some research today and for the Medicaid expansion states, I think all but 2 or 3 (AR and CT were ones I could identify) are using private insurance to fulfill the coverage.

That's how it looks here, too.  When you go to your regular doctor and they ask for your insurance information, you just tell them Medicaid instead of blue cross or whatever.  We see it often from other patients when we're checking in the kids.

We also get asked frequently after that if we qualify, because there are apparently a bunch of additional services that doctors push that our regular insurance doesn't cover, for things like developmental specialists or nutrition counseling.  They seem much more focused on preventative care for Medicaid recipients.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Eric on August 18, 2015, 07:19:04 PM
The simplest way to push your MAGI above 138% FPL and stay off Medicaid is to do Roth conversions. Is that not an option for you?

Agreed.  Another option is to take out a second mortgage on your house and invest it, which would artificially increase your expenses/income. 
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Gin1984 on August 18, 2015, 07:25:43 PM
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.
Eh, I had a friend with lupus in Northern California and had great docs including specialists.  I know because she could not drive and I drove her a couple of times.  They even let her get a same day appointment when something weird happened during school.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: EscapeVelocity2020 on August 18, 2015, 08:11:45 PM
...and another idea, if you really want to think outside the box, is that many other countries have better healthcare at much more reasonable prices.  Hence the advent of 'medical tourism', which is also a nice way of saying that, if you have concerns about ongoing healthcare cost, then you are probably better living elsewhere.  Even countries with universal coverage will give you a much better deal on more comprehensive private treatment than the US gives it's insured citizens on anything, just go to a 'private healthcare facility' over there.

It is ridiculous that Capitalism totally failed in such an important market, but it really did.  Undeniably.  And that really raises 'red flags' (but wait, doesn't red mean 'communism', which might get me flagged?  Oops, I said flag and red again.  Shit).  Damn :)
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: FIRE me on August 18, 2015, 09:04:59 PM
It is ridiculous that Capitalism totally failed in such an important market, but it really did.  Undeniably.  And that really raises 'red flags' (but wait, doesn't red mean 'communism', which might get me flagged?  Oops, I said flag and red again.  Shit).  Damn :)

Capitalism in health care didn't fail at all. Capitalism is making huge profits for insurance companies, drug companies, and hospitals. In the eyes of capitalism, beyond lip service the patient was never any priority.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: EscapeVelocity2020 on August 18, 2015, 10:00:05 PM
Capitalism in health care didn't fail at all. Capitalism is making huge profits for insurance companies, drug companies, and hospitals. In the eyes of capitalism, beyond lip service the patient was never any priority.
Sorry FM, I was just thinking of myself, as I sometimes do on this forum :)  Seriously, there should be a balance struck between the basic health of the nation paying taxes to a central government and the benefits paid out in terms of reasonable coverage against preventable disease.  Too many people in the US end up in the emergency room and don't have and insurance. 
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 18, 2015, 10:11:24 PM
Capitalism in health care didn't fail at all.

Agreed. I might even go so far as to say that American health care is one of the greatest examples of capitalism ever implemented.  Think of all the profits!

The key is that capitalism doesn't care about people.  It cannot value saving lives or minimizing suffering or curing disease, only making money.  By definition, it is about maximizing profits at the expense of all other considerations.

But I'm secretly kind of a pinko who thinks capitalism isn't always the best choice for managing some of our social systems.  Health care. Environmental protection. Civil rights.  Representative democracy.  All of these things have been ruined in America by capitalism, yet capitalism is still the nation's one defining feature and the one reason our government exists.

I don't expect to see an election in my lifetime that isn't primarily about "the economy" aka promoting capitalist profits above all else.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Hamster on August 19, 2015, 12:13:20 AM
Medicaid is a very mixed bag - and varies a lot by state. My experience, with about 35% of my patients being on Medicaid, is it does a good job of giving patients access to unnecessary stuff (free Tylenol!) and major stuff (hospitalizations, major surgeries, etc), but it drops off a lot of services in the middle, and it adds a lot of work to providers and dumps a lot of costs off on others.

I get paid the same regardless of what insurance my patients have, but I have have to do way more fighting with our Medicaid plans than with any other insurer to get patients what they need.

Medicaid is oriented toward people with low income so there are no co-pays - whatever gets covered is fully covered, and there are things like taxis to appointments and OTC meds like Tylenol, and infant vitamin D drops that Medicaid will cover, but private insurance won't. They try to minimize these costs by making you fill out tons of paperwork though.

On the other hand, there are many things that are much harder to get covered. The WA State Medicaid plans (Molina) have very restrictive and often arbitrary formularies for prescription medications. For example, they cover the mildest topical medication for acne, but if that's not strong enough, the doc has to jump through hoops to get stronger medication, even though it doesn't cost any more. And here, no durable medical equipment is covered, meaning if a doc gives a sling, walking boot, or crutches, Medicaid won't pay for it. In practice, the provider's office ends up giving the equipment away because they can almost never collect from the patient either. Medicaid dumps the cost on the doctor's office.

Also Medicaid is exempt from many of the ACA requirements for covered services. So while the ACA mandates that plans cover certain preventive developmental screenings, our Medicaid plan doesn't pay for them. What a nightmare trying to figure out how to bill certain (non-grandfathered) private plans, but not Medicaid or grandfathered plans. It is pretty much impossible, so we just don't bill for these services, and eat the costs.

Average Medicaid reimbursement is about 60% that of private insurance, so many providers won't accept it. There was a time in the greater Seattle area that no orthopedists accepted Medicaid other than Univ of Washington and Seattle Children's. It was an access nightmare. That said, I only have so much sympathy for guys making as much as the orthopedists make...

Where we are, mental health contracting with Medicaid is also a mess. They have the state divided into regions, so someone with the exact same Medicaid plan in county A where wait times are months, can't see a psychiatrist in county B where wait times are a few days, even though both psychiatrists accept the exact same Medicad plan.

Dental can also be variable. In many cases they will pay for extraction, but not implants. So you can get dental care, for free, but that means a hole in your smile where they pull a tooth, but nothing to fill that hole. Many dentists here accept Medicaid when they first open their practices, but once they start filling up they don't take Medicaid any longer because it reimburses much lower.

Anyway. Despite all of the above, I would gladly take a single payer system in the U.S.   If everyone had Medicaid, things would even out, and Medicaid reimbursement would have to go up since there wouldn't be anyone else to eat those costs. The variability is a nightmare, so having one uniform plan, at least we would know what is covered consistently, and not have to deal with so many different players who all follow different rules.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Cressida on August 19, 2015, 12:19:08 AM
...useful commentary...

Thanks for this - as a WA resident I appreciated the info. My coverage is with Group Health, and I vastly prefer it to any other provider (I've had several, thank you batshit employer-based health care system), but my understanding is that they don't accept Medicaid. So if I were to retire and ended up in the Medicaid window, I wouldn't be able to use my preferred provider, which stinks.

Yes, single-payer is definitely the answer. What an utter mess this is.

edit: terminology
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 19, 2015, 12:47:13 AM
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Axecleaver on August 19, 2015, 08:48:37 AM
Hamster, that was a quality post, thanks for the provider side of the story.

Regarding admin costs for providers, the estimates I've seen are around 1/3rd of a provider's overhead goes toward managing the billing  process. I've done some work in this area with EHR's, which promised to help lower costs, but ended up making things worse for most providers. Some of the high end provider practices I've worked with have steadfastly refused to go to an EHR, giving up significant incentives, because they're such a nightmare to deal with. Single payer would fix this.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 19, 2015, 09:00:58 AM
Medicaid is oriented toward people with low income so there are no co-pays - whatever gets covered is fully covered

It depends on the state and whether you are part of a group exempt from copays (like children) or getting services exempt from copays (like family planning). Otherwise states can charge copays at their discretion. WA may be one of the smart ones that doesn't.

Also Medicaid is exempt from many of the ACA requirements for covered services. So while the ACA mandates that plans cover certain preventive developmental screenings, our Medicaid plan doesn't pay for them. What a nightmare trying to figure out how to bill certain (non-grandfathered) private plans, but not Medicaid or grandfathered plans. It is pretty much impossible, so we just don't bill for these services, and eat the costs.
Traditional Medicaid is exempt from the preventive services requirements (with the exception for tobacco cessation for pregnant women and pharmacotherapy tobacco cessation products for non-pregnant women). But beneficiaries of the Medicaid expansion get all of the same preventive services (over 100 including newborn screening) as non-grandfathered health plans without cost sharing.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Mr. Green on August 19, 2015, 10:09:38 AM
"Medicaid is great coverage."

I hope you get the chance to be covered by Medicaid someday.  Same outcomes?  Maybe, for the few people that get to see a doctor.  Medicaid in California, called Medi-Cal, is pretty much the same as no health insurance.  Few doctors take it, even fewer specialists. 

Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.
My father is on Medicaid in North Carolina and it has been a wonderful experience compared to no insurance. As the person who has to manage his money, I have been pleasantly surprised with how well Medicaid has worked out.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: EscapeVelocity2020 on August 19, 2015, 11:04:58 AM
It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance. 

Coming in to this discussion as an engineer, I agree that it is totally insane.  Nobody, in this day and age, should ever subject our citizenry to such a duplicitous, ridiculous system without being called a traitor to our country :)   Unfortunately, many seem to want to opt back in to the patchwork, unregulated fleecing that came before it.  That is the beauty of having a truly horrific third-world system (except it insults other countries that do healthcare better, sorry Djibouti...)
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 19, 2015, 12:35:04 PM
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: EscapeVelocity2020 on August 19, 2015, 12:53:41 PM
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 19, 2015, 01:17:33 PM
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: beltim on August 19, 2015, 01:25:58 PM
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).

Forummm and I have disagreed on this before, and I've argued that the US should be spending more like 2/3 of what we pay now, because we're significantly richer than most of the comparison countries (http://forum.mrmoneymustache.com/welcome-to-the-forum/obamacare-survives/msg761407/#msg761407).  This works out to be about $6,000 per person per year.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 19, 2015, 01:36:38 PM
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).

Forummm and I have disagreed on this before, and I've argued that the US should be spending more like 2/3 of what we pay now, because we're significantly richer than most of the comparison countries (http://forum.mrmoneymustache.com/welcome-to-the-forum/obamacare-survives/msg761407/#msg761407).  This works out to be about $6,000 per person per year.

I'd be happy to save the $1T we both agree on and work towards the extra $500B :)
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: beltim on August 19, 2015, 01:39:11 PM
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).

Forummm and I have disagreed on this before, and I've argued that the US should be spending more like 2/3 of what we pay now, because we're significantly richer than most of the comparison countries (http://forum.mrmoneymustache.com/welcome-to-the-forum/obamacare-survives/msg761407/#msg761407).  This works out to be about $6,000 per person per year.

I'd be happy to save the $1T we both agree on and work towards the extra $500B :)

Agreed.  I just thought it would be useful to give EV another number.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: BCBiker on August 19, 2015, 04:03:14 PM
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.

One of the "amazing that they needed to include in the law" features of ACA is that insurance companies have to spend 80-85% of premium dollars on actual care. Unfortunately, the robbers that health insurance companies are have not really followed through... http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study (http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study)

I am a huge proponent of ACA. Single-payer would be better but I think the law is doing a lot of good for a lot of people, and the FIRE crowd probably benefits more than anyone else.  I hate how people treat Obamacare as if it is some bogeyman.  It has been amazingly successful at many things (not all things however...)

To OP, if you can get Medicaid at no cost to you, you would be crazy not to unless it is causing you a moral dilemma (You ask yourself whether you want to take money that is meant to be a safety net for the poor, not a financially independent person.) I don't pass judgement. I think it is up to you. Just don't trash ACA, thinking that your $50 pre-Obamacare policy was actually an insurance policy (as others have described it was essentially worthless for all intents and purposes). 
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 19, 2015, 04:33:01 PM
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.

One of the "amazing that they needed to include in the law" features of ACA is that insurance companies have to spend 80-85% of premium dollars on actual care. Unfortunately, the robbers that health insurance companies are have not really followed through... http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study (http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study)

I am a huge proponent of ACA. Single-payer would be better but I think the law is doing a lot of good for a lot of people, and the FIRE crowd probably benefits more than anyone else.  I hate how people treat Obamacare as if it is some bogeyman.  It has been amazingly successful at many things (not all things however...)


Many years ago, I came up with a very simple plan that would have made the ACA entirely unnecessary, as well as had effects similar to a single payer system without the downsides of the political screw-ups.

It hinged on one simple tax rule change...

That any individual, corporation, institution or legal entity within the United States could donate towards the medical bills of any particular individual, either physically located within the United States, or otherwise a US citizen abroad.  All such donated funds would be 100% deductible for the donator so long as the medicine, procedure, whatever was a recognized medical practice for the malady in question, and was documented as available as an experimental procedure at least 50 years prior.

We can quibble about the actual time frame or details about the recognition of a deductible medical bill, but in practice there would be a whole new medical industry that popped up just to be able to both avoid paying the government taxes and get some political good will out of major corporations and high-income earning individuals.  Medical insurance would gravitate towards covering the 'gap' that the delay creates, as well as negotiating reasonable rates for the non-deductible portion.  This is the same effect that compelled businesses to offer medical insurance in the US to begin with, because it was all deductable to them anyway, and a better than average medical plan could be used to attract employees.  At present, it's actually quite difficult for an individual to deduct medical expenses for himself, much less for another person.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: beltim on August 19, 2015, 04:37:17 PM
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 19, 2015, 04:49:14 PM
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?

Because it already occurs in limited contexts.  Surgeons, doctors & nurses donate time & expertise to civic health clinics.  Corporations donate to charities for both the deduction as well as the "goodwill equity" such actions create.  Religious institutions have benefited from such a wide open deduction for a very long time, and many of them are health care related.  If more incentive is actually necessary, than a 103% or 105% deduction rate might help motivate the tight-fisted.  But the way that I imagine it is that people who actually know someone who needs the help will give what they can, and benefit from the tax deduction in the following year.  The delay in deductable procedures would function mostly to limit deduction fraud, preventing people from inventing new procedures just to create new tax shelters.

EDIT: Think about it like this.  Groceries (i.e. unprepared food) is exempt from sales taxes just about everywhere, under the argument that food is a basic human need.  A similar argument applies to actual health care, but not health insurance.  It's not the actual insured rate that's important, but the access to health care.  If almost everyone could reasonablely expect to either 1) pay for their own medical expenses or if they couldn't afford it 2) get someone else to pay for it; then there really wouldn't be a need to worry about the rate of insured.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: beltim on August 19, 2015, 04:51:47 PM
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?

Because it already occurs in limited contexts.  Surgeons, doctors & nurses donate time & expertise to civic health clinics.  Corporations donate to charities for both the deduction as well as the "goodwill equity" such actions create.  Religious institutions have benefited from such a wide open deduction for a very long time, and many of them are health care related.  If more incentive is actually necessary, than a 103% or 105% deduction rate might help motivate the tight-fisted.  But the way that I imagine it is that people who actually know someone who needs the help will give what they can, and benefit from the tax deduction in the following year.  The delay in deductable procedures would function mostly to limit deduction fraud, preventing people from inventing new procedures just to create new tax shelters.

Sure, that might work if people would get more money back than they donated - it would be an instant profit to do so. But then it's costing the government just as much as a single payer program would.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 19, 2015, 05:12:29 PM
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.

One of the "amazing that they needed to include in the law" features of ACA is that insurance companies have to spend 80-85% of premium dollars on actual care. Unfortunately, the robbers that health insurance companies are have not really followed through... http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study (http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study)

I am a huge proponent of ACA. Single-payer would be better but I think the law is doing a lot of good for a lot of people, and the FIRE crowd probably benefits more than anyone else.  I hate how people treat Obamacare as if it is some bogeyman.  It has been amazingly successful at many things (not all things however...)

To OP, if you can get Medicaid at no cost to you, you would be crazy not to unless it is causing you a moral dilemma (You ask yourself whether you want to take money that is meant to be a safety net for the poor, not a financially independent person.) I don't pass judgement. I think it is up to you. Just don't trash ACA, thinking that your $50 pre-Obamacare policy was actually an insurance policy (as others have described it was essentially worthless for all intents and purposes).

It's pretty easy to game the MLR.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 19, 2015, 05:14:00 PM
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?

Because it already occurs in limited contexts.  Surgeons, doctors & nurses donate time & expertise to civic health clinics.  Corporations donate to charities for both the deduction as well as the "goodwill equity" such actions create.  Religious institutions have benefited from such a wide open deduction for a very long time, and many of them are health care related.  If more incentive is actually necessary, than a 103% or 105% deduction rate might help motivate the tight-fisted.  But the way that I imagine it is that people who actually know someone who needs the help will give what they can, and benefit from the tax deduction in the following year.  The delay in deductable procedures would function mostly to limit deduction fraud, preventing people from inventing new procedures just to create new tax shelters.

Sure, that might work if people would get more money back than they donated - it would be an instant profit to do so. But then it's costing the government just as much as a single payer program would.

Maybe, but the ideological objection to single payer plans, including my own (libertarian) objection, ceases to exist.  If your desire is to reduce the overhead of medical care, and hopefully extend health care access to as many people as possible; then a single payer system should not be your only path under consideration.  However, there are those who have a political motive to promote single payer, and those who have a political motive to oppose it; so it's really a non-starter already.  Single payer will never survive long in the United States, simply because it's too divisive an issue here; no matter how badly each party screws up the medical services market in the meantime.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 19, 2015, 05:30:10 PM
Single payer will never survive long in the United States, simply because it's too divisive an issue here; no matter how badly each party screws up the medical services market in the meantime.

I'm not convinced of that.

Single payer doesn't have to displace private health insurance, it just has to be available to everyone as their base insurance.  The Medicaid expansion already covers a significant portion of the country.  Medicare and tricare cover most of the rest.  It's just this little slice of people in the middle that don't yet have access to subsidized health care, and the ACA gives those people access to subsidized health insurance instead, which is almost the same thing but retains our nightmarish billing bureaucracy.

Private health insurance will always exist for people who want it, but I don't think anyone should be allowed to suffer and die by virtue of being too poor to afford it.  We could effectively negotiate a quasi-single-payer system by raising the income limit for Medicaid and lowering the age limit for Medicare.  The only people left would be young wealthy people who don't need either anyway, and at that point they would probably cry foul for being singled out, so we could just extend it to them too.  Make the new higher tax rates required to pay it all less progressive than the current system so the rich get proportionally cheaper care than the dirty poor, and they still get to buy as much Cadillac plan coverage as they want on the remaining private market.  Everyone wins!
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 19, 2015, 05:56:49 PM
  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it.  Just subsidizing health care for everyone still forces other people to pay for it.  In the current case, it's the young and not yet born generation that is going to be saddled with the debt, which is morally unacceptable in my view.  Also, the use of legalized coercion that is the largest issue for myself, not the end result.  Do it my way, and those who can't pay for it themselves have as good a chance at convincing someone else to pay for it as convincing conservatives to support single payer without repeal, without coercion.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Hamster on August 19, 2015, 06:11:16 PM
If you want to read a fantastic summary of why our healthcare is so expensive, why our insurance system results in such distorted pricing, and the most interesting proposal I have heard to reform it,  check out this article in the Atlantic (http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/). You have to scroll through 3/4 of the article to "A Way Forward" before the author proposes his solution.

The basic idea is:
On average, a person will contribute 1.8 million dollars over a lifetime to health care (as of 2009, with very conservative future growth estimates). Much of this is wasted on administration and price distortions which we have discussed before and are outlined in the first 3/4 of the article.
To fix this, he proposes that we address the pricing dilemma caused by our current system of health insurance which combines indeminity insurance and routine costs (What we have now in health "insurance" is akin to auto insurance that pays for oil changes and brake repair), and the opacity of a system where nobody knows what they are paying:

1) For catastrophic coverage (i.e. real insurance needs) - everyone would have the same insurance that is basically a VERY high-deductible plan. Since the deductible would be so high (e.g. $50,000), premiums would be very low. 
2) For routine care, everyone would be mandated to contribute to an HSA - (as we are now mandated to contribute to Medicare). People who earn below a certain amount would have the government contribute on their behalf. Price could be around $5000 per year, for example, and would accumulate for life. If you got above a certain threshold based on age, you could stop contributing (or withdraw the amount in excess), and any funds left when you die could become part of your estate (eliminate the 'use it or lose it' issue we have with much care now).
3) All of your medical care is paid directly by you, from your HSA, until you meet your VERY high deductible, then the catastrophic plan takes over. If there is a gap - costs above the HSA balance, but below the Catastrophic deductible, then you borrow against the future contributions to your HSA.
4) To ensure that people actually performed preventive services - one option would be that vouchers would be issued for preventive care that had evidence that it is beneifical.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 19, 2015, 06:11:53 PM
  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it. 

Why impossible?  I suggested expanding entitlements and raising taxes to pay for it, as a mechanism for reducing wasteful overhead costs we've already agreed plague our current system.  Remove some of the profit motive from healthcare, and maybe we can get back to improving outcomes for the patients instead just making money for the shareholders.

Quote
]Just subsidizing health care for everyone still forces other people to pay for it.

But we already do that under the current system.  Anybody who pays for insurance is currently subsidizing all those folks who are legally guaranteed care even if they can't afford it.  My proposed version just makes this discrepancy more obvious to everyone, instead of letting conservatives believe that a private health insurance market is somehow more equitable because they can pretend EMTALA doesn't exist.

Quote
Do it my way, and those who can't pay for it themselves have as good a chance at convincing someone else to pay for it

I'm not comfortable making health care access dependent on charity.  What about unpopular people with no friends?  What about persecuted religious minorities? 

I'm fine with the notion of granting tax deductions for medical donations, but I'd rather those donations go into supporting/subsidizing a single payer system available to everyone than have it be the mechanism by which some people are granted care and others are denied it.  That just seems like a recipe for abuse.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: EscapeVelocity2020 on August 19, 2015, 06:23:10 PM

Agreed.  I just thought it would be useful to give EV another number.


Thanks, and interesting.  Let's just say that, in terms of raw numbers, there are whole countries of difference between where the estimates stand.  At a number like 6k pp, I imagine people are shocked.  Yet this (or probably more) is what us youngsters are paying toward Medicare recipients without even knowing it...
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 19, 2015, 06:24:25 PM
If you want to read a fantastic summary of why our healthcare is so expensive, why our insurance system results in such distorted pricing, and the most interesting proposal I have heard to reform it,  check out this article in the Atlantic (http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/). You have to scroll through 3/4 of the article to "A Way Forward" before the author proposes his solution.

The basic idea is:


That would work also.  Another way would be to automaticly open HSA's for every child born, which are not accessible by parents alone, and are partially funded by tax dollars at certain life stages; say $10k at birth, another $10K at age 10, and again at 15 or so.  While this would not remove the coercion issue, one can make the argument that those funds are advances on the future income taxes of a healthy and productive adult.

My root argument is that the current (and recent past) state of the medical industry is so riddled with counterproductive tax rules, regulations and opaque financing schemes that it can't be fixed.  It simply must be replaced wholesale, but that I (and many others) cannot support single payer for ideological reasons.  It may survive anyway, but as divided as this nation is right now, I doubt that the ACA survives the next Republican presidency intact.  It will be "reformed" in some fashion or another.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 19, 2015, 06:38:25 PM
  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it. 

Why impossible?  I suggested expanding entitlements and raising taxes to pay for it, as a mechanism for reducing wasteful overhead costs we've already agreed plague our current system.  Remove some of the profit motive from healthcare, and maybe we can get back to improving outcomes for the patients instead just making money for the shareholders.

Because, using your own example, shareholders won't win.  Somebody has to pay the bill, and that will fall upon someone; no matter how the taxes are raised.  BTW, we are those shareholders.  Shareholders are not typically fat-cats, but aspiring retirees.

Quote
Quote
]Just subsidizing health care for everyone still forces other people to pay for it.

But we already do that under the current system.  Anybody who pays for insurance is currently subsidizing all those folks who are legally guaranteed care even if they can't afford it.  My proposed version just makes this discrepancy more obvious to everyone, instead of letting conservatives believe that a private health insurance market is somehow more equitable because they can pretend EMTALA doesn't exist.


Yes, I know.

Quote

Quote
Do it my way, and those who can't pay for it themselves have as good a chance at convincing someone else to pay for it

I'm not comfortable making health care access dependent on charity.  What about unpopular people with no friends?  What about persecuted religious minorities? 

What about them?  We have a history of doing exactly this kind of thing in this country, quite successfully, prior to World War 1.  Mostly via "mutual assistance societies", which were the model for union health plans not long afterwards.  Notice, if you will, that persecuted minorities of every sort had their own societies.  Despite the bigoted nature of the age, the groups that formed these societies did fairly well.

https://en.wikipedia.org/wiki/Benefit_society

They were eventually undermined because they were typically discriminatory towards their own groups, and their success tended to undermine the 'collective bargaining' power of the AMA.  Also, they were ad hoc compared to a modern system, but some similar systems still exist.

http://christianpf.com/christian-health-insurance-alternative/
http://www.chministries.org/

Quote

I'm fine with the notion of granting tax deductions for medical donations, but I'd rather those donations go into supporting/subsidizing a single payer system available to everyone than have it be the mechanism by which some people are granted care and others are denied it.  That just seems like a recipe for abuse.

How do you see such a system working under my proposal?  And why would you expect that it would be a worse problem than it already is?
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Hamster on August 19, 2015, 06:40:41 PM
...
My root argument is that the current (and recent past) state of the medical industry is so riddled with counterproductive tax rules, regulations and opaque financing schemes that it can't be fixed.  It simply must be replaced wholesale, but that I (and many others) cannot support single payer for ideological reasons.  It may survive anyway, but as divided as this nation is right now, I doubt that the ACA survives the next Republican presidency intact.  It will be "reformed" in some fashion or another.
I absolutely agree that the current system is a disaster which has been growing for decades. I don't think the ACA addresses the root causes, and doesn't begin to get costs under control. It did bring forward increased coverage for young adults (up to 26), eliminated the issue with pre-existing conditions, and lifetime caps. These are very good things, and will continue in whatever system replaces our current one, which will have to happen before too much longer.

I think that much of the current policy focus is misguided, for example HITECH act's obsession with 'meaningful use' incentives and penalties for using computerized medical records in certain ways. It mostly results in a huge infrastructure to show that people have checked off a bunch of boxes without actually improving patient care or health in any measurable way. Many providers are finding that they are better off not even trying to comply, and accepting the Medicare penalties. For example a geriatrician who doesn't have a certain percentage of her elderly patients sending e-mails to the electronic medical record will lose the incentives and/or pay penalties...
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 19, 2015, 07:16:48 PM
Single payer will never survive long in the United States, simply because it's too divisive an issue here; no matter how badly each party screws up the medical services market in the meantime.

I'm not convinced of that.

Single payer doesn't have to displace private health insurance, it just has to be available to everyone as their base insurance.  The Medicaid expansion already covers a significant portion of the country.  Medicare and tricare cover most of the rest.  It's just this little slice of people in the middle that don't yet have access to subsidized health care, and the ACA gives those people access to subsidized health insurance instead, which is almost the same thing but retains our nightmarish billing bureaucracy.

Private health insurance will always exist for people who want it, but I don't think anyone should be allowed to suffer and die by virtue of being too poor to afford it.  We could effectively negotiate a quasi-single-payer system by raising the income limit for Medicaid and lowering the age limit for Medicare.  The only people left would be young wealthy people who don't need either anyway, and at that point they would probably cry foul for being singled out, so we could just extend it to them too.  Make the new higher tax rates required to pay it all less progressive than the current system so the rich get proportionally cheaper care than the dirty poor, and they still get to buy as much Cadillac plan coverage as they want on the remaining private market.  Everyone wins!

With the most recent numbers from 1st qtr 2015, about 64.5% had private insurance (up from 59.5% in 2013), 34.6% had public insurance (up from 33.8% in 2013), and 9.2% were uninsured (down from 14.4% in 2013). Numbers don't add to 100% due to rounding. People were mostly in private insurance before the ACA, and the ACA mostly put uninsured people into private insurance. Public insurance includes Medicare.

I agree that one good option is to lower the Medicare age and raise the Medicaid age. And Medicare and Medicaid could still continue to contract with private insurers as they do now, using accountable care organizations and managed care organizations (so the incentive is to keep people healthier and not needing the expensive care). But because there would be one payer, the incentives would be aligned (say investing now to keep people healthier in the long run and for agriculture policies), and billing would be simplified, and there would be much better negotiating ability (so we start paying what France and Japan pay for drugs, etc).

  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it. 

Actually, everyone would win in a system such as I described. Everyone except the people who the extra $1 trillion plus in waste is going to (but isn't that part of capitalism where the waste is cast aside and left to find their own way?). Everyone else would have their costs dropped dramatically. I haven't gotten into your plan, but it's completely unworkable.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 19, 2015, 07:29:17 PM
If you want to read a fantastic summary of why our healthcare is so expensive, why our insurance system results in such distorted pricing, and the most interesting proposal I have heard to reform it,  check out this article in the Atlantic (http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/). You have to scroll through 3/4 of the article to "A Way Forward" before the author proposes his solution.

The basic idea is:
On average, a person will contribute 1.8 million dollars over a lifetime to health care (as of 2009, with very conservative future growth estimates). Much of this is wasted on administration and price distortions which we have discussed before and are outlined in the first 3/4 of the article.
To fix this, he proposes that we address the pricing dilemma caused by our current system of health insurance which combines indeminity insurance and routine costs (What we have now in health "insurance" is akin to auto insurance that pays for oil changes and brake repair), and the opacity of a system where nobody knows what they are paying:

1) For catastrophic coverage (i.e. real insurance needs) - everyone would have the same insurance that is basically a VERY high-deductible plan. Since the deductible would be so high (e.g. $50,000), premiums would be very low. 
2) For routine care, everyone would be mandated to contribute to an HSA - (as we are now mandated to contribute to Medicare). People who earn below a certain amount would have the government contribute on their behalf. Price could be around $5000 per year, for example, and would accumulate for life. If you got above a certain threshold based on age, you could stop contributing (or withdraw the amount in excess), and any funds left when you die could become part of your estate (eliminate the 'use it or lose it' issue we have with much care now).
3) All of your medical care is paid directly by you, from your HSA, until you meet your VERY high deductible, then the catastrophic plan takes over. If there is a gap - costs above the HSA balance, but below the Catastrophic deductible, then you borrow against the future contributions to your HSA.
4) To ensure that people actually performed preventive services - one option would be that vouchers would be issued for preventive care that had evidence that it is beneifical.

I think this is an interesting idea, but I think it might be worse than what we have now (post-ACA). $50k is an insanely high deductible. The average person would have a lot of trouble putting $5k/person into the HSA each year. A family of 5 now has $25k to put in, plus premiums, plus retirement accounts, plus college savings, plus mortgage, food, etc? That's a lot. And you still have all the existing problems where you as a consumer have no idea what you really need and what it will actually cost you and whether it's worth it or not. That's too much overhead for a consumer. They are just not equipped to make those decisions correctly. I think it's much better for people to just get the care that they actually need (ideally no more, no less) based on the best medical judgment (made by experts taking the patient preferences into account, but not by the uninformed patients). And when the people making the decision have their financial rewards at play, they will be motivated to make good decisions. If you pay a plan a capitated rate adjusted for quality measures they will strive to keep costs down while keeping quality up. I am a very educated consumer of healthcare and I would not be able to make all the right decisions for my family. It would be overly burdensome even for me.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 19, 2015, 08:49:33 PM
But because there would be one payer, the incentives would be aligned (say investing now to keep people healthier in the long run and for agriculture policies), and billing would be simplified, and there would be much better negotiating ability (so we start paying what France and Japan pay for drugs, etc).
Perhaps, but I would think it more likely that a single payer system would suffer from the 'central planning' failures because there is only one payer.  This is a big country, and if markets are inhibited from finding their equilibrium then there will be inefficiencies.  It may take years, but a single payer system is likely to develop imbalances in some fashion or another, such as very real cost differences between regions for certain types of treatment.  For example, geriatric care, if the single payer system doesn't account for market forces, could be really cheap where old people are over represented because there are more geriatric doctors to choose from, or it may be more expensive if there are not enough geriatric doctors in the area.  A free-ish market in non-emergency medical care would self-correct for such market imbalances over time, whereas a central planning type pricing system would not and eventually be noticablely out of balance.  A single payer system could be designed with a free-sh market element to deal with such issues, but I haven't seen one as such yet.  Keep in mind that all of the single payer systems that have worked so "well" in Europe & Canada (ha!) vary between nations, but not typically between regions within nations.  As such, such single payer systems represent smaller populations over smaller geographic areas than the US system would.  Even so, it seems that the smallest & least diverse populations have the, seemingly, best functioning single payer systems.  For example, Sweden seems to manage it's issues better than Britain, which seems to do better than France.  Corrolation is not causation, but I don't think that those issues are just corrolation.  I think that most of the single payer systems that exist don't scale very well, and would not translate well to a nation with as much population, diversity and geographic dispersion as the US.  The Russian Federation has a subidized system that is a bit of a cross between Obamacare (i.e. mandated insurance) and single payer, and their health care stats are abysmal.
Quote

  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it. 

Actually, everyone would win in a system such as I described. Everyone except the people who the extra $1 trillion plus in waste is going to (but isn't that part of capitalism where the waste is cast aside and left to find their own way?).

Yes, but as you should already know, capitalism is not what we have now.  Certainly not in the health care industry.  As such, there are way too many people who are economicly or ideologically motivated to oppose single payer to ever let it have a good chance to succeed; even if it could be engineered to actually work.

Quote

 Everyone else would have their costs dropped dramatically.
I heard the same claims prior to the ACA, but that hasn't panned out either.
Quote
I haven't gotten into your plan, but it's completely unworkable.

Why is it unworkable?  The beauty of my plan is that it's just simple.  Complexity is often a systems killer.  Look at the ACA.  They had to pass it before anyone could see what was in it, after all, because the bill was so complex and ripe with graft that no one could honestly claim to know how it would work in practice.  My idea is simply to incentiveize health cost sharing & charity in as simple a fashion as possible, and see how far such incentives can take us.  If health care really is a human right, then perhaps a true tax credit would be better; but I'm simply limiting it to the health care options available a generation or two ago.  It could be a thirty year span, or whatever was available before an individual was born.  The delay exists only as a bandpass filter for established treatments.  No matter how it's set up, the public, on average, is going to have to pay for it's own health care.  My simple method would not fix everything, but it doesn't have to be in order to be a 'workable' success.  It only need to be an improvement, on the aggregate, to the current status quo; which despite the ACA remains an epic mess.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Hamster on August 20, 2015, 12:06:34 AM
If you want to read a fantastic summary of why our healthcare is so expensive, why our insurance system results in such distorted pricing, and the most interesting proposal I have heard to reform it,  check out this article in the Atlantic (http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/). You have to scroll through 3/4 of the article to "A Way Forward" before the author proposes his solution.

The basic idea is:
On average, a person will contribute 1.8 million dollars over a lifetime to health care (as of 2009, with very conservative future growth estimates). Much of this is wasted on administration and price distortions which we have discussed before and are outlined in the first 3/4 of the article.
To fix this, he proposes that we address the pricing dilemma caused by our current system of health insurance which combines indeminity insurance and routine costs (What we have now in health "insurance" is akin to auto insurance that pays for oil changes and brake repair), and the opacity of a system where nobody knows what they are paying:

1) For catastrophic coverage (i.e. real insurance needs) - everyone would have the same insurance that is basically a VERY high-deductible plan. Since the deductible would be so high (e.g. $50,000), premiums would be very low. 
2) For routine care, everyone would be mandated to contribute to an HSA - (as we are now mandated to contribute to Medicare). People who earn below a certain amount would have the government contribute on their behalf. Price could be around $5000 per year, for example, and would accumulate for life. If you got above a certain threshold based on age, you could stop contributing (or withdraw the amount in excess), and any funds left when you die could become part of your estate (eliminate the 'use it or lose it' issue we have with much care now).
3) All of your medical care is paid directly by you, from your HSA, until you meet your VERY high deductible, then the catastrophic plan takes over. If there is a gap - costs above the HSA balance, but below the Catastrophic deductible, then you borrow against the future contributions to your HSA.
4) To ensure that people actually performed preventive services - one option would be that vouchers would be issued for preventive care that had evidence that it is beneifical.

I think this is an interesting idea, but I think it might be worse than what we have now (post-ACA). $50k is an insanely high deductible.
I am enjoying this discussion, but I feel you are looking at single-payer with overly rosey glasses, and not applying the same scrutiny/skepticism you apply to other forms of financing. Step back for a second and try to see the benefits and ways to overcome some of the hurdles you appropriately identify.

You have to remember you would have had contributions coming into your HSA since the year you were born.
Most people would easily have many 10s of thousands of dollars in their HSA by the time they reach adulthood. Also, $50k is really just pulled out of a hat. Maybe $20-$30k is more appropriate. I honestly don't think the deductibles would be very different between a $30k and $50k deductible plan.

The average person would have a lot of trouble putting $5k/person into the HSA each year. A family of 5 now has $25k to put in, plus premiums, plus retirement accounts, plus college savings, plus mortgage, food, etc? That's a lot.
strikethrough: We need to be comparing health care costs to health care costs. Adding the rest in there is not relevant and is a bit of a cheap rhetorical trick. You could just as well say "How could we pay for higher taxes to cover a single payer plan when we have to pay for groceries, housing, yadda yadda?"

We are not talking about paying more over a lifetime, just rearranging when and how that money is contributed to change price pressures and distortional pricing mechanisms in the current system. Remember, right now we are projected to spend over $22k per year per person over a lifetime in healthcare costs. That makes $5k mandatory contribution less than 1/4 of healthcare costs. But $5k is just a number thrown out there. It may be less. This could also be taken out as mandatory payroll deduction, so it is really not that different from what is going on now. Also, depending on income, that family of 5 could have some or all of that $5k per year paid for in government contributions.

Those numbers may sound big, but right now we are already paying that, just hidden and to a large extent deducted from your payroll as:
1) Premiums -employee and employer
2) Medicare contributions- employee and employer
3) HSA or FSA contributions
4) Copay, coinsurance, deductible, out of pocket expenses
All of those numbers would be rolled up into the $5k per person, plus VERY low premiums for a very high deductible plan.

Last year, my employee and employer contributions to my insurance premiums alone were $21.5k for a crappy plan for a family of 4 - (abso-fucking-lutely insane - rememer this is just premiums, not actual care). $3.5k was my contribution, the rest was hidden as employer contributions. This year I am on a high deductible plan and combined premiums are already over $13k. That doesnt' include medicare. It doesn't include FSA/HSA contributions. It doesn't include copays. For me $5k a year per person would be cheaper. And premiums on a $50k deductible insurance plan would be minimal - most of premiums in our current state are going to costs that would be covered by the putative HSA in the plan above.

And you still have all the existing problems where you as a consumer have no idea what you really need and what it will actually cost you and whether it's worth it or not. That's too much overhead for a consumer. They are just not equipped to make those decisions correctly. I think it's much better for people to just get the care that they actually need (ideally no more, no less) based on the best medical judgment (made by experts taking the patient preferences into account, but not by the uninformed patients).
By this you mean the care itself? Usually that argument is in regards to insurance - that people don't know what insurance they need until they need it, and have no way to know what is covered. Under the putative BIG HSA plan, it would still be the physician making recommendations and the healthcare 'consumer' making choices based on those recommendations. Costs would actually be completely transparent - services would actually compete on price - if there is an MRI at one facility that will charge you $900 for a knee MRI, and another will charge you $700, you are probably going to choose the cheaper one.
A single payer system doesn't fix the issue of patients knowing what care they need, or where they should go for it. There is also the moral hazard issue of patients wanting care they don't need because they aren't paying for it.

And when the people making the decision have their financial rewards at play, they will be motivated to make good decisions. If you pay a plan a capitated rate adjusted for quality measures they will strive to keep costs down while keeping quality up.
It sounds great in theory, but in practice is just as prone to manipulation as fee-for-service plans are. Capitation crashed and burned in the 90s and was thrown away before current efforts to ressurect it, augmented with big-data. Capitation alone creates adverse selection - nobody wants the sickest or most difficult patients if you get paid the same for them. If you try to adjust capitation for illness severity, you get more questionable diagnoses - hmmm... maybe that excitable kid deserves a diagnosis of ADHD... maybe instead of checking that blood pressure again to see if today's high number was a fluke, that patient should a diagnosis of hypertension - Yay. now I get paid more because my severity adjusted capitation rates went up. As for quality - hmmm... all of my hypertensive patients are getting their blood pressure under control except for Mrs. Jones - I am going to discharge her from my practice because she is non-compliant. Yay, my quality scores for hypertension control just improved. The more you regulate/monitor to avoid these manipulations, the more you have to spend on insuring compliance.

The only way to avoid these shenanigans is to pay a straight salary, which has its own inefficiencies. That said, some of the best practices in the US do just that, as do many single payer systems.

I am a very educated consumer of healthcare and I would not be able to make all the right decisions for my family. It would be overly burdensome even for me.
I honestly don't understand what you mean. What extra burden is there, compared to what we are doing now? The burden of seeing the prices of the care you are going to receive and that the prices would be deducted from your account instead of prices being opaque, paid by an insurer and you have no idea what your personal liability will be until after the fact? You wouldn't be self-diagnosing your appendicitis or deciding yourself if you should have surgery versus antibiotics just because you are paying from an HSA.

I honestly think a single payer is probably the most realistic way to 'fix' healthcare in the US, but it does come with a HUGE host of problems as well, and I am very skeptical that a single payer plan has a chance unless we have a financial collapse much worse than the most recent one. I think the above plan would honestly be an easier sell... but in either case you would have to contend with completely eliminating the current health insurance industry, which would be very hard to get through any congress.

Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 20, 2015, 10:13:36 AM
If you want to read a fantastic summary of why our healthcare is so expensive, why our insurance system results in such distorted pricing, and the most interesting proposal I have heard to reform it,  check out this article in the Atlantic (http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/). You have to scroll through 3/4 of the article to "A Way Forward" before the author proposes his solution.

The basic idea is:
On average, a person will contribute 1.8 million dollars over a lifetime to health care (as of 2009, with very conservative future growth estimates). Much of this is wasted on administration and price distortions which we have discussed before and are outlined in the first 3/4 of the article.
To fix this, he proposes that we address the pricing dilemma caused by our current system of health insurance which combines indeminity insurance and routine costs (What we have now in health "insurance" is akin to auto insurance that pays for oil changes and brake repair), and the opacity of a system where nobody knows what they are paying:

1) For catastrophic coverage (i.e. real insurance needs) - everyone would have the same insurance that is basically a VERY high-deductible plan. Since the deductible would be so high (e.g. $50,000), premiums would be very low. 
2) For routine care, everyone would be mandated to contribute to an HSA - (as we are now mandated to contribute to Medicare). People who earn below a certain amount would have the government contribute on their behalf. Price could be around $5000 per year, for example, and would accumulate for life. If you got above a certain threshold based on age, you could stop contributing (or withdraw the amount in excess), and any funds left when you die could become part of your estate (eliminate the 'use it or lose it' issue we have with much care now).
3) All of your medical care is paid directly by you, from your HSA, until you meet your VERY high deductible, then the catastrophic plan takes over. If there is a gap - costs above the HSA balance, but below the Catastrophic deductible, then you borrow against the future contributions to your HSA.
4) To ensure that people actually performed preventive services - one option would be that vouchers would be issued for preventive care that had evidence that it is beneifical.

I think this is an interesting idea, but I think it might be worse than what we have now (post-ACA). $50k is an insanely high deductible.
I am enjoying this discussion, but I feel you are looking at single-payer with overly rosey glasses, and not applying the same scrutiny/skepticism you apply to other forms of financing. Step back for a second and try to see the benefits and ways to overcome some of the hurdles you appropriately identify.

You have to remember you would have had contributions coming into your HSA since the year you were born.
Most people would easily have many 10s of thousands of dollars in their HSA by the time they reach adulthood. Also, $50k is really just pulled out of a hat. Maybe $20-$30k is more appropriate. I honestly don't think the deductibles would be very different between a $30k and $50k deductible plan.

The average person would have a lot of trouble putting $5k/person into the HSA each year. A family of 5 now has $25k to put in, plus premiums, plus retirement accounts, plus college savings, plus mortgage, food, etc? That's a lot.
strikethrough: We need to be comparing health care costs to health care costs. Adding the rest in there is not relevant and is a bit of a cheap rhetorical trick. You could just as well say "How could we pay for higher taxes to cover a single payer plan when we have to pay for groceries, housing, yadda yadda?"

We are not talking about paying more over a lifetime, just rearranging when and how that money is contributed to change price pressures and distortional pricing mechanisms in the current system. Remember, right now we are projected to spend over $22k per year per person over a lifetime in healthcare costs. That makes $5k mandatory contribution less than 1/4 of healthcare costs. But $5k is just a number thrown out there. It may be less. This could also be taken out as mandatory payroll deduction, so it is really not that different from what is going on now. Also, depending on income, that family of 5 could have some or all of that $5k per year paid for in government contributions.

Those numbers may sound big, but right now we are already paying that, just hidden and to a large extent deducted from your payroll as:
1) Premiums -employee and employer
2) Medicare contributions- employee and employer
3) HSA or FSA contributions
4) Copay, coinsurance, deductible, out of pocket expenses
All of those numbers would be rolled up into the $5k per person, plus VERY low premiums for a very high deductible plan.

Last year, my employee and employer contributions to my insurance premiums alone were $21.5k for a crappy plan for a family of 4 - (abso-fucking-lutely insane - rememer this is just premiums, not actual care). $3.5k was my contribution, the rest was hidden as employer contributions. This year I am on a high deductible plan and combined premiums are already over $13k. That doesnt' include medicare. It doesn't include FSA/HSA contributions. It doesn't include copays. For me $5k a year per person would be cheaper. And premiums on a $50k deductible insurance plan would be minimal - most of premiums in our current state are going to costs that would be covered by the putative HSA in the plan above.

And you still have all the existing problems where you as a consumer have no idea what you really need and what it will actually cost you and whether it's worth it or not. That's too much overhead for a consumer. They are just not equipped to make those decisions correctly. I think it's much better for people to just get the care that they actually need (ideally no more, no less) based on the best medical judgment (made by experts taking the patient preferences into account, but not by the uninformed patients).
By this you mean the care itself? Usually that argument is in regards to insurance - that people don't know what insurance they need until they need it, and have no way to know what is covered. Under the putative BIG HSA plan, it would still be the physician making recommendations and the healthcare 'consumer' making choices based on those recommendations. Costs would actually be completely transparent - services would actually compete on price - if there is an MRI at one facility that will charge you $900 for a knee MRI, and another will charge you $700, you are probably going to choose the cheaper one.
A single payer system doesn't fix the issue of patients knowing what care they need, or where they should go for it. There is also the moral hazard issue of patients wanting care they don't need because they aren't paying for it.

And when the people making the decision have their financial rewards at play, they will be motivated to make good decisions. If you pay a plan a capitated rate adjusted for quality measures they will strive to keep costs down while keeping quality up.
It sounds great in theory, but in practice is just as prone to manipulation as fee-for-service plans are. Capitation crashed and burned in the 90s and was thrown away before current efforts to ressurect it, augmented with big-data. Capitation alone creates adverse selection - nobody wants the sickest or most difficult patients if you get paid the same for them. If you try to adjust capitation for illness severity, you get more questionable diagnoses - hmmm... maybe that excitable kid deserves a diagnosis of ADHD... maybe instead of checking that blood pressure again to see if today's high number was a fluke, that patient should a diagnosis of hypertension - Yay. now I get paid more because my severity adjusted capitation rates went up. As for quality - hmmm... all of my hypertensive patients are getting their blood pressure under control except for Mrs. Jones - I am going to discharge her from my practice because she is non-compliant. Yay, my quality scores for hypertension control just improved. The more you regulate/monitor to avoid these manipulations, the more you have to spend on insuring compliance.

The only way to avoid these shenanigans is to pay a straight salary, which has its own inefficiencies. That said, some of the best practices in the US do just that, as do many single payer systems.

I am a very educated consumer of healthcare and I would not be able to make all the right decisions for my family. It would be overly burdensome even for me.
I honestly don't understand what you mean. What extra burden is there, compared to what we are doing now? The burden of seeing the prices of the care you are going to receive and that the prices would be deducted from your account instead of prices being opaque, paid by an insurer and you have no idea what your personal liability will be until after the fact? You wouldn't be self-diagnosing your appendicitis or deciding yourself if you should have surgery versus antibiotics just because you are paying from an HSA.

I honestly think a single payer is probably the most realistic way to 'fix' healthcare in the US, but it does come with a HUGE host of problems as well, and I am very skeptical that a single payer plan has a chance unless we have a financial collapse much worse than the most recent one. I think the above plan would honestly be an easier sell... but in either case you would have to contend with completely eliminating the current health insurance industry, which would be very hard to get through any congress.

I'm not sure why you are talking about single payer. I was comparing the $50k deductible idea to what we have today. I was saying I thought today was better than the $50k deductible idea. I also think single payer is better than what we have today, but that's another topic. There are also a lot of other improvements on what we have today other than single payer. If you look around the other developed nations, there are many different models (many are not even single payer). I believe ours is the worst value of any of the developed nations.

If the $50k number is picked at random, why not $12,700k? Which happens to be the OOP max for a household Marketplace plan. And there are plenty of complaints that even this number is far too high. I think it's OK. You won't go bankrupt. And you can use an HSA (but with lower, and not legally enforced required contributions). And there are cost sharing reductions for lower income people. I think it's mistake to require a huge fixed-dollar amount of money to be spent on something without regards to people's other obligations. The ACA tax credit system is nice because it essentially caps the amount you spend on premiums based on your income, and cost sharing is also capped based on income too for those <250%FPL. Far from being "a rhetorical trick", my point is that the $50k plan will be making it much harder for average-income people to get by vs the status quo. If I make the median household income with a wife and 3 kids, my ACA plan would cost around $200 per month and my OOP max would be around $2k for the family for the year. Very reasonable. The $50k plan, with $25k going into HSAs (half my income!!) is a big hardship by comparison.

The $22k/person/year figure is not in today's dollars so it is useless as a comparator to your current annual expense.

I like how prices are magically transparent. We have lots of HSAs and HDHPs now and prices are anything but transparent. But let's say we pass a law that all prices for all services must be displayed on the Internet. Great! Let's do that now. It doesn't matter whether it's ACA or $50k plan, that would be beneficial. (although some people would choose to pay more for something because they would think that a higher price means a higher value--this happens all the time in other goods). So set that aside, since it's independent of any policy we're dicussing.

The problem is that the average person doesn't know how to evaluate whether a service is worth the cost. The provider says "I recommend it". OK. But is it worth the cost? I have to evaluate that. With medicine, the average person does not have the ability to do that well. You'd still be relying on the advice of the person who would be selling you the service. Even honest providers would disagree over whether something was medically useful for a particular patient. It's hard for a patient to assess all this well.

Nothing is free from gaming. But it works much better in other countries. I suggest we move towards something that works better.

Under the capitation system, one company could have everyone in a state. Hard to use adverse selection there.

I would absolutely be deciding whether to have surgery or antibiotics. That's the exact kind of thing I'd have to weigh. And exactly what I would be bad at. The surgeon may not tell me that just taking antibiotics is an option. But if he were honest and did tell me that, I'd have to make that decision since one is much more expensive than the other.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Tyson on August 20, 2015, 01:55:47 PM

That would work also.  Another way would be to automaticly open HSA's for every child born, which are not accessible by parents alone, and are partially funded by tax dollars at certain life stages; say $10k at birth, another $10K at age 10, and again at 15 or so.  While this would not remove the coercion issue, one can make the argument that those funds are advances on the future income taxes of a healthy and productive adult.

My root argument is that the current (and recent past) state of the medical industry is so riddled with counterproductive tax rules, regulations and opaque financing schemes that it can't be fixed.  It simply must be replaced wholesale, but that b]I (and many others) cannot support single payer for ideological reasons.[/b]  It may survive anyway, but as divided as this nation is right now, I doubt that the ACA survives the next Republican presidency intact.  It will be "reformed" in some fashion or another.

I'm just curious.  If we assume for just a moment (just play along with me here) that single payer is, in fact, the best solution to this problem, would you still oppose it?

And please don't dodge the question by saying some variation of "But it can NEVER be the best answer because xyz".
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Hamster on August 20, 2015, 02:07:32 PM
I believe ours is the worst value of any of the developed nations.
No real argument here.
If the $50k number is picked at random, why not $12,700k? Which happens to be the OOP max for a household Marketplace plan.
The deductible would be much higher than in the current system because everyone would have an HSA that had been accruing contributions (either personal or governmental) from birth, so there would be a built-in mechanism to cover the costs between zero and the deductible. In the current system there isn't - HSA/FSA is currently optional and the government does not contribute.
There would also likely need to be a lifetime max built into the high deductible portion for out of pocket costs.
The ACA tax credit system is nice because it essentially caps the amount you spend on premiums based on your income, and cost sharing is also capped based on income too for those <250%FPL. Far from being "a rhetorical trick", my point is that the $50k plan will be making it much harder for average-income people to get by vs the status quo. If I make the median household income with a wife and 3 kids, my ACA plan would cost around $200 per month and my OOP max would be around $2k for the family for the year. Very reasonable. The $50k plan, with $25k going into HSAs (half my income!!) is a big hardship by comparison.

You are forgetting the government contributions that would replace current govt subsidies, a huge portion of our medicare contributions, etc. It would be subsidized similar to subsidies we have now. Again, there are very few situations where you will exhaust the HSA and not reach the high deductible. In those situations, there can be borrowing against future HSA contributions. Premiums for a $50k plan would be a tiny fraction of what current premiums are.

I like how prices are magically transparent. We have lots of HSAs and HDHPs now and prices are anything but transparent.

There is no magic needed. Prices are already transparent for people paying at cash-only practices. Go get Lasik, you know the price up front. Go get cosmetic surgery or braces,you know the price up front. The  reason prices are currently opaque for most services is because of how charges are negotiated with insurance. Nobody knows what you will be billed. If I tell you our standard charge is $500 for a 99214 level visit, it means absolutely nothing. Every insurance plan in every insurance company has different negotiated rates - your insurance could have that negotiated down to anywhere from $100-$475, and you may be on hook for any or all of that.

As soon as you have people paying cash from an HSA for everything and eliminate the insurance middleman, prices are suddenly transparent. No magic needed.

But let's say we pass a law that all prices for all services must be displayed on the Internet. Great! Let's do that now.
Unless you eliminate the ability for different insurers to negotiate different rates, that is effectively impossible.

The problem is that the average person doesn't know how to evaluate whether a service is worth the cost. The provider says "I recommend it". OK. But is it worth the cost? I have to evaluate that. With medicine, the average person does not have the ability to do that well. You'd still be relying on the advice of the person who would be selling you the service. Even honest providers would disagree over whether something was medically useful for a particular patient. It's hard for a patient to assess all this well.

In any system, with any degree of autonomy you still run into the issue of deciding which diagnostic/therapeutic route to take - private insurance, single payer, anything. Do you follow the physicians' advice or not? Do you do your own "research" on google, or ask your neighbor whose cousin is a naturopath?
The cost factor may complicate it for some. It already does now. And remember the costs are coming out of an HSA in the VAST majority of circumstances.
Under the capitation system, one company could have everyone in a state. Hard to use adverse selection there.
Capitation and size/monopoly status are essentially unrelated issues. Under a capitated plan you can have as many or as few insurers as you want in a given region. With one insurer per state the insurer can determine prices as a monopoly. That is not necessarily beneificial for anyone other than the insurer. Why should state lines matter?

You are talking about adverse selection from the insurer side. My examples are related to adverse selection by health care providers. This is a very well-described problem with capitation, and one of the reasons the US capitated-managed-care-experiment failed miserably in the 1990s and almost everyone went back to fee for service. Providers don't want high utilization patients in your practice under a capitated model. It costs extra time for no added reimbursement.

I would absolutely be deciding whether to have surgery or antibiotics. That's the exact kind of thing I'd have to weigh. And exactly what I would be bad at. The surgeon may not tell me that just taking antibiotics is an option. But if he were honest and did tell me that, I'd have to make that decision since one is much more expensive than the other.
People are having to make these same decisions now. They just don't have any idea what the cost difference will be.

Anyway, this is a thought experiment to a large extent. I think there are ways to think of solutions to the issues you bring up. It's much more fun/productive to challenge yourself to think of what could be tweaked to make such a system work.
[Edit: grammar fixes]
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 20, 2015, 06:27:04 PM
. I believe ours is the worst value of any of the developed nations.


I think that depends upon what, exactly, you value.

Quote

I like how prices are magically transparent. We have lots of HSAs and HDHPs now and prices are anything but transparent.

The idea is that as HSA's become more common, and therefore individuals take more 'ownership' of their own medical care funds, market forces will compel the disclosure of prices.  I have seen some movement in this area, in part, because I actually ask.  It is possible to get prices down, even with the same provider.  This is particularly true if you are willing to pay as you go, rather than after the insurance pays their part.  I did this exact trick with my son's braces, paid a little with each visit, but not enough to cover all of it.  One of the greater cost pressures in medical care, generally, is the overhead of collecting on medical debt.  Most any hospital will jack up their costs somewhat to cover the possibility that you not pay your bills in any timely manner, and they will be forced to 'sell' that debt to a debt collector at a discount.  If you pay as you go, you won't be a collection problem for them, and can generally negotiate a discount for non-emergency care.

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The problem is that the average person doesn't know how to evaluate whether a service is worth the cost. The provider says "I recommend it". OK. But is it worth the cost? I have to evaluate that. With medicine, the average person does not have the ability to do that well. You'd still be relying on the advice of the person who would be selling you the service. Even honest providers would disagree over whether something was medically useful for a particular patient. It's hard for a patient to assess all this well.

True, but this is also true with just about every other product or service.  Would the average person know if which water heater is the better value, if not for Consumer Reports?  What about a car?  We, as consumers can try to educate ourselves, or we can seek the opinions of other educated people.  This is a good reason that WebMD.com is such a successful website. 

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Nothing is free from gaming. But it works much better in other countries. I suggest we move towards something that works better.


This statement is based upon what, exactly?  In what way does it work "better", and which countries?  The details vary so dramaticly that this statement can only be an opinion.

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Under the capitation system, one company could have everyone in a state. Hard to use adverse selection there.


That would be a state sponsored monopoly.  There are so many things wrong with that idea alone.

Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 20, 2015, 06:32:27 PM

That would work also.  Another way would be to automaticly open HSA's for every child born, which are not accessible by parents alone, and are partially funded by tax dollars at certain life stages; say $10k at birth, another $10K at age 10, and again at 15 or so.  While this would not remove the coercion issue, one can make the argument that those funds are advances on the future income taxes of a healthy and productive adult.

My root argument is that the current (and recent past) state of the medical industry is so riddled with counterproductive tax rules, regulations and opaque financing schemes that it can't be fixed.  It simply must be replaced wholesale, but that b]I (and many others) cannot support single payer for ideological reasons.[/b]  It may survive anyway, but as divided as this nation is right now, I doubt that the ACA survives the next Republican presidency intact.  It will be "reformed" in some fashion or another.

I'm just curious.  If we assume for just a moment (just play along with me here) that single payer is, in fact, the best solution to this problem, would you still oppose it?

Yes, I would.  For many ideological reasons.  Fundamentally, even if a single payer system would result in the best overall medical outcomes, it's will still be a state monopoly over a significant industry.  Monopolies, and particularly politically structured monopolies, create their own problems & injustices external to the simple question of whether they are effective at their actual mission.  This is why I said that I did not believe that a single-payer system would long survive in the United States, it's practical effectiveness notwithstanding.  There simply are too many people like myself.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 20, 2015, 07:19:43 PM
Yes, I would.  For many ideological reasons.  Fundamentally, even if a single payer system would result in the best overall medical outcomes, it's will still be a state monopoly over a significant industry.  Monopolies, and particularly politically structured monopolies, create their own problems & injustices external to the simple question of whether they are effective at their actual mission.  This is why I said that I did not believe that a single-payer system would long survive in the United States, it's practical effectiveness notwithstanding.  There simply are too many people like myself.

I think most of our state sponsored monopolies are doing pretty well, all things considered.  I'm sure you don't need me to point them out to you, but I'll offer you a few anyway. 

Medicare seems pretty awesome, why can't that work for more people?  And I think our military is better than any other, I'd hate to break them up so that private corporations could compete to "more efficiently" store and deliver nuclear weapons. 

Some things are just better run as natural monopolies, despite your historical conditioning that profit-seeking is the morally superior way to run a society.  I'm pretty sure the US military would not be improved by breaking up their monopoly on national defense, but I'd like to hear you talk about why this particular state sponsored monopoly is okay but others are not.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Tyson on August 20, 2015, 07:23:16 PM

That would work also.  Another way would be to automaticly open HSA's for every child born, which are not accessible by parents alone, and are partially funded by tax dollars at certain life stages; say $10k at birth, another $10K at age 10, and again at 15 or so.  While this would not remove the coercion issue, one can make the argument that those funds are advances on the future income taxes of a healthy and productive adult.

My root argument is that the current (and recent past) state of the medical industry is so riddled with counterproductive tax rules, regulations and opaque financing schemes that it can't be fixed.  It simply must be replaced wholesale, but that b]I (and many others) cannot support single payer for ideological reasons.[/b]  It may survive anyway, but as divided as this nation is right now, I doubt that the ACA survives the next Republican presidency intact.  It will be "reformed" in some fashion or another.

I'm just curious.  If we assume for just a moment (just play along with me here) that single payer is, in fact, the best solution to this problem, would you still oppose it?

Yes, I would.  For many ideological reasons.  Fundamentally, even if a single payer system would result in the best overall medical outcomes, it's will still be a state monopoly over a significant industry.  Monopolies, and particularly politically structured monopolies, create their own problems & injustices external to the simple question of whether they are effective at their actual mission.  This is why I said that I did not believe that a single-payer system would long survive in the United States, it's practical effectiveness notwithstanding.  There simply are too many people like myself.

Hey, thanks for answering honestly and directly, I appreciate the insight.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 20, 2015, 10:05:34 PM

I think most of our state sponsored monopolies are doing pretty well, all things considered.  I'm sure you don't need me to point them out to you, but I'll offer you a few anyway. 

There are exactly two monopolies mentioned in the US Constitution, and they exist to counterbalance one another.  They are copyrights & the Library of Congress.

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Medicare seems pretty awesome, why can't that work for more people?
I don't agree.  Medicare works.  I don't agree that it works well.  That said, Medicare is not a monopoly.  It's another form of subsidized health insurance, with state by state differences.  Some states administer it directly, some states contract that out to private operators; but I'm pretty sure they all have a semi-private option, which can be turned down.  I believe that would be called 'Part B'. 

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 And I think our military is better than any other, I'd hate to break them up so that private corporations could compete to "more efficiently" store and deliver nuclear weapons. 

Even our military isn't a monopoly, even if it's the only option our government chooses to exercise.  The Constitution defined two other options, which could be utilized independently or in conjunction.  The first was the independent militia, which in some fashion state guards actually are; and the other is the 'letter of marque', which is basicly a warrant issued by the POTUS to be carried out by a private contractor.  A letter of marque would typically define the person(s) wanted by the president, and the acceptable methods of capture or destruction.   Since a letter of marque only had effect outside of the territorial control of the presidency; it was, in effect, a document that 'deputized' an individual contractor and his employees.  Although there is no evidence that those particular words were ever used, GW Bush was known to have issued orders to Blackwater, either directly or indirectly.  Such orders were arguablely 'letters of marque'.
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Some things are just better run as natural monopolies, despite your historical conditioning that profit-seeking is the morally superior way to run a society.

A natural monopoly is one thing, but if a law needs to be passed, it's not an example of a natural monopoly.  There are, actually, very few examples of persistent natural monopolies.  Furthermore, you assume too much.  I grew up in a borderline socialist household, and was a Green as a young man.  I know from experience that the accusation that Greens are watermelons, green on the outside and red on the inside, is generally true. 

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  I'm pretty sure the US military would not be improved by breaking up their monopoly on national defense, but I'd like to hear you talk about why this particular state sponsored monopoly is okay but others are not.

You will not get to hear that argument from myself.  I worked for them once.  They are not as good at their job as it might appear from afar.  I have come to agree with Thomas Jefferson; that professional, standing armies are a threat to both liberty and democracy.  Furthermore, the US Constitution doesn't actually permit a professional army, and forces congress to re-authorize ours every two years...

" The Congress shall have Power To ...raise and support Armies, but no Appropriation of Money to that Use shall be for a longer Term than two Years....
    Article I, Section 8, Clause 12

This clause was intended to permit Congress to force the president to disband a standing army, by denying ongoing funding to that army.  It seems to have never worked that way.

 I have no answer to the nuclear arms issue beyond that governments shouldn't possess them either.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 20, 2015, 11:13:13 PM
There are exactly two monopolies mentioned in the US Constitution, and they exist to counterbalance one another.  They are copyrights & the Library of Congress.

So you don't think Post Offices count?  The Constitution enumerates that authority specifically.

And I still think the military counts.  As does our voting infrastructure and a handful of other services for which the the US federal government is the sole service provider.  Firefighting on federal lands.  Tax collection.  Interstate highways.  Tribal liasons.  Regulating airwaves.  Nuclear waste repositories.  Unemployment insurance.  Space exploration, until very recently.  There all kinds of things that the US has decreed they alone will provide, without competition from the private sector, because they provide for the general welfare and need doing regardless of profit motive.

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I don't agree.  Medicare works.  I don't agree that it works well.  That said, Medicare is not a monopoly.  It's another form of subsidized health insurance, with state by state differences.

As discussed above, the form of "single-payer" that most people want is closer to expanded Medicare than the Candadian monopoly model (which also grew out of their version of Medicare).  Care is still provided by private practices, but a government negotiates pricing and simplifies billing.  It could still be run by each state instead of the feds (also like Canada).  Would still be a huge improvement over what we had before, and probably over what we have now.

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Even our military isn't a monopoly, even if it's the only option our government chooses to exercise. 

I'm not sure that a never-used clause in the Constitution negates the practical effects of the US military's monopoly on national defense.  We'll never see Blackwater successfully petition Congress for funding, they only work at the request of US military command.

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A natural monopoly is one thing, but if a law needs to be passed, it's not an example of a natural monopoly. 

That seems a subtle distinction.  The Constitution itself had to be passed, after all, like any other law. 

Quote
They are not as good at their job as it might appear from afar. 

I agree that our military is sometimes grossly inefficient.  Fortunately they have such heaping piles of money that they've managed to be the most effective fighting force on the planet despite a whole host of internal problems.  I don't think any other nation, or even coalition of nations, could seriously challenge the US military.  That's a relatively recent development and it won't last forever, but it's the state of the world today.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Cressida on August 20, 2015, 11:48:15 PM
I'm personally convinced that if only everyone was packing heat, suddenly an unregulated market would produce magic health care for all.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 21, 2015, 01:29:24 AM
There are exactly two monopolies mentioned in the US Constitution, and they exist to counterbalance one another.  They are copyrights & the Library of Congress.

So you don't think Post Offices count?  The Constitution enumerates that authority specifically.


You've misread it.  The Constitution granted Congress the power to establish postal routes and post offices, but not necessarily as a monopoly on postal delivery as a service.

"The Clause has been construed to give Congress the enumerated power to designate mail routes and construct or designate post offices, with the implied authority to carry, deliver, and regulate the mails of the United States as a whole. An early controversy was whether Congress had the power to actually build post roads and post offices, or merely designate which lands and roads were to be used for this purpose, and to what extent that power could be delegated to the Postmaster General.[6] The U.S. Supreme Court construed the power narrowly during the early part of the 19th century, holding that the power consisted mostly of designation of roads and sites, but gradually gave way later on, allowing appropriation of land for postal purposes."

https://en.wikipedia.org/wiki/Postal_Clause

Ironicly, prior to the implied monopoly interpretation, the delivery of mail in the colonies, as well as pretty much all of Europe as far as I am aware, was performed by private contractors.  It wasn't until John Quincy Adams was elected president that the concept of the post offices & postal roads as an intergrated communications system as we know it today became popular, due to JQA's public speaches on the improvements of national infrastructure, for which he considered a coherent, and federally regulated, postal service to be a paramount part.  Both his father, John Adams, and Thomas Jefferson were appalled at the idea of a United States Postal Service.  Jefferson believed the USPS would be a institution of political patronage.  Neither the framers of the Constitution, nor the delegates that debated and voted upon this clause, ever imagined that the postal clause authorized a publicly supported enterprise with a state monopoly.

Furthermore, the USPS has had very real competitors in the past, as well as the present.  Some were ran out of business, others still exist.  UPS is just one example.

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And I still think the military counts. 
You can think what you like, but you asked me to defend your belief.  So, no.

Quote

As does our voting infrastructure and a handful of other services for which the the US federal government is the sole service provider.


I'll grant you the voting infrastructure, although there are better ways to do even that today.  What other services do you consider the US Federal government to be the sole provider, and why do you think they are natural monopolies again?

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Firefighting on federal lands.
Is actually performed by a variety of providers, including private contractors and state fire departments.
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Tax collection.
Does not qualify as a public service.  Is arguablely theft by fiat, but not a service.  Certainly not one that a free market would demand.
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Interstate highways.
Are legally justified by the 'postal roads' clause mentioned above, but were neither constructed by, nor currently maintained by, federal employees.  Also not a service, per se.  Roads are infrastructure.  The body of work debunking the "who will build the roads?" complaint against libertarian thought is massive.  If you really are interested in this debate, this alone will require a new thread.
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Tribal liasons.
Wait, what?
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Regulating airwaves.
Only because there is an international treaty that requires it.  The electromatic spectrum is a tragedy of the commons in so many ways.  Also, not really a service; at least not one the free market would demand.  The early history of the radio broadcasting industry is rather interesting in it's own right. We still lumber along with the lingering effects of the anti-competitive actions of huge corporations using laws as a bludgen to eliminate their smaller competitors during that time.
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Nuclear waste repositories.
Not one of which has been built by the Federal government, despite a legal requirement to do so.  Every single nuclear waste repository in the United States is privately owned by some power company. Period.
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Unemployment insurance.
Not a monopoly.  I have private unemployment insurance as part of my work benefits package.
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Space exploration, until very recently.
Why did you bother?  And only due to the cost of the technology, which could be argued was a natural monopolies for super-power governments due to the incredible up front costs.  But like all natural monopolies, it was a temporary market condition.
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There all kinds of things that the US has decreed they alone will provide, without competition from the private sector, because they provide for the general welfare and need doing regardless of profit motive.
That they decreed?  Well, sure.  But that isn't a natural monopoly by definition. 
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I don't agree.  Medicare works.  I don't agree that it works well.  That said, Medicare is not a monopoly.  It's another form of subsidized health insurance, with state by state differences.

As discussed above, the form of "single-payer" that most people want is closer to expanded Medicare than the Candadian monopoly model (which also grew out of their version of Medicare).  Care is still provided by private practices, but a government negotiates pricing and simplifies billing.  It could still be run by each state instead of the feds (also like Canada).  Would still be a huge improvement over what we had before, and probably over what we have now.


I don't agree with any of what you just said above.
Quote
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Even our military isn't a monopoly, even if it's the only option our government chooses to exercise. 

I'm not sure that a never-used clause in the Constitution negates the practical effects of the US military's monopoly on national defense.
It has been used.
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  We'll never see Blackwater successfully petition Congress for funding, they only work at the request of US military command.

So?  Is Blackwater something different than a privately paid, trained and equipt army?

Quote
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A natural monopoly is one thing, but if a law needs to be passed, it's not an example of a natural monopoly. 

That seems a subtle distinction.  The Constitution itself had to be passed, after all, like any other law. 

Subtle, perhaps.  But a distinction nonetheless.  The method by which the US Constitution was ratified was an order of magnitude more complex, and more democratic, than anything that has happened since.  Even an amendment is easier, and no amendment could pass today; even many that actually exist.

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They are not as good at their job as it might appear from afar. 

I agree that our military is sometimes grossly inefficient.  Fortunately they have such heaping piles of money that they've managed to be the most effective fighting force on the planet despite a whole host of internal problems.

That was your money, not their money.  Governments have no money honestly earned.

Quote

 I don't think any other nation, or even coalition of nations, could seriously challenge the US military.  That's a relatively recent development and it won't last forever, but it's the state of the world today.

If war is economics by other means, then that day will come sooner than later.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 21, 2015, 08:51:29 AM

I think most of our state sponsored monopolies are doing pretty well, all things considered.  I'm sure you don't need me to point them out to you, but I'll offer you a few anyway. 

There are exactly two monopolies mentioned in the US Constitution, and they exist to counterbalance one another.  They are copyrights & the Library of Congress.

Quote

Medicare seems pretty awesome, why can't that work for more people?
I don't agree.  Medicare works.  I don't agree that it works well.  That said, Medicare is not a monopoly.  It's another form of subsidized health insurance, with state by state differences.  Some states administer it directly, some states contract that out to private operators; but I'm pretty sure they all have a semi-private option, which can be turned down.  I believe that would be called 'Part B'. 

Quote

 And I think our military is better than any other, I'd hate to break them up so that private corporations could compete to "more efficiently" store and deliver nuclear weapons. 

Even our military isn't a monopoly, even if it's the only option our government chooses to exercise.  The Constitution defined two other options, which could be utilized independently or in conjunction.  The first was the independent militia, which in some fashion state guards actually are; and the other is the 'letter of marque', which is basicly a warrant issued by the POTUS to be carried out by a private contractor.  A letter of marque would typically define the person(s) wanted by the president, and the acceptable methods of capture or destruction.   Since a letter of marque only had effect outside of the territorial control of the presidency; it was, in effect, a document that 'deputized' an individual contractor and his employees.  Although there is no evidence that those particular words were ever used, GW Bush was known to have issued orders to Blackwater, either directly or indirectly.  Such orders were arguablely 'letters of marque'.
Quote

Some things are just better run as natural monopolies, despite your historical conditioning that profit-seeking is the morally superior way to run a society.

A natural monopoly is one thing, but if a law needs to be passed, it's not an example of a natural monopoly.  There are, actually, very few examples of persistent natural monopolies.  Furthermore, you assume too much.  I grew up in a borderline socialist household, and was a Green as a young man.  I know from experience that the accusation that Greens are watermelons, green on the outside and red on the inside, is generally true. 

Quote

  I'm pretty sure the US military would not be improved by breaking up their monopoly on national defense, but I'd like to hear you talk about why this particular state sponsored monopoly is okay but others are not.

You will not get to hear that argument from myself.  I worked for them once.  They are not as good at their job as it might appear from afar.  I have come to agree with Thomas Jefferson; that professional, standing armies are a threat to both liberty and democracy.  Furthermore, the US Constitution doesn't actually permit a professional army, and forces congress to re-authorize ours every two years...

" The Congress shall have Power To ...raise and support Armies, but no Appropriation of Money to that Use shall be for a longer Term than two Years....
    Article I, Section 8, Clause 12

This clause was intended to permit Congress to force the president to disband a standing army, by denying ongoing funding to that army.  It seems to have never worked that way.

 I have no answer to the nuclear arms issue beyond that governments shouldn't possess them either.

You like to provide strong opinions on things when you don't have much information about them. For example, Medicare is entirely a federal program. No state-level differentiation. Nearly all senior citizens have it. If that's not a monopoly, my economics textbooks may need to be rewritten. There are many private plans that provide a supplement to Medicare (like paying your copays and coinsurance for you) that are either purchased or provided as an employee retirement benefit. Generally the only senior citizens that are not enrolled in Medicare are those that live abroad and those that are still working and receive employer-sponsored coverage. The US government also has a pretty strong lock on the market for "defending the US from foreign invasion", and is also a monopoly provider of that service.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 21, 2015, 12:49:48 PM

You like to provide strong opinions on things when you don't have much information about them.


Generally I do have information about them.

Quote

For example, Medicare is entirely a federal program. No state-level differentiation.

I was confusing Medicaid and Medicare.  Sorry about that.

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Nearly all senior citizens have it. If that's not a monopoly, my economics textbooks may need to be rewritten.
Actually, no.  Medicare is more accurately a monopsony, because it is a single buyer of third party services.  So would 'single payer' likely be.  I was using the term 'monopoly' because I didn't realize I was dealing with an economicly educated individual.  The problems created are of a similar nature, so I was using the layman's term.  I think we may just be talking past each other, or I'm getting my responders confused.  I'm not in favor of monopsonies either.  Every person over 65 does indeed have Medicare Part A, but that is just a catastrophic hospital plan; and not remotely comparable to a comprehensive health insurance plan, such that Obamacare now requires that everyone else purchase by law.  That's like saying that every wage employee has unemployment insurance through the state.  Well, of course they do, because they pay the premiums (through their employer) because they don't have a choice.  However, Medicare Part B is a subsidized private insurance program; that is voluntary and requires additional premiums.  I also have private unemployment insurance, over and above what my state mandated employment insurance happens to be.  Neither example is actually the only provider of such a service, but both are examples of such a service that must be paid for by law.

https://en.wikipedia.org/wiki/Monopsony

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 There are many private plans that provide a supplement to Medicare (like paying your copays and coinsurance for you) that are either purchased or provided as an employee retirement benefit.


You are talking about Part B and Medigap type programs above.

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Generally the only senior citizens that are not enrolled in Medicare are those that live abroad and those that are still working and receive employer-sponsored coverage.

I'm confused.  Are you arguing that Medicare is a natural monopoly?  Or a state-mandated one?

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 The US government also has a pretty strong lock on the market for "defending the US from foreign invasion", and is also a monopoly provider of that service.

I already noted that the US military is, at present, a monopoly provider of national defense services.  But the original claim was that it was so because of of the US Constitution, and
I was challenged to defend such a state monopoly.  It was easy to prove that was not the case, originally.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Gin1984 on August 21, 2015, 01:59:13 PM

You like to provide strong opinions on things when you don't have much information about them.


Generally I do have information about them.

Quote

For example, Medicare is entirely a federal program. No state-level differentiation.

I was confusing Medicaid and Medicare.  Sorry about that.

Quote
Nearly all senior citizens have it. If that's not a monopoly, my economics textbooks may need to be rewritten.
Actually, no.  Medicare is more accurately a monopsony, because it is a single buyer of third party services.  So would 'single payer' likely be.  I was using the term 'monopoly' because I didn't realize I was dealing with an economicly educated individual.  The problems created are of a similar nature, so I was using the layman's term.  I think we may just be talking past each other, or I'm getting my responders confused.  I'm not in favor of monopsonies either.  Every person over 65 does indeed have Medicare Part A, but that is just a catastrophic hospital plan; and not remotely comparable to a comprehensive health insurance plan, such that Obamacare now requires that everyone else purchase by law.  That's like saying that every wage employee has unemployment insurance through the state.  Well, of course they do, because they pay the premiums (through their employer) because they don't have a choice.  However, Medicare Part B is a subsidized private insurance program; that is voluntary and requires additional premiums.  I also have private unemployment insurance, over and above what my state mandated employment insurance happens to be.  Neither example is actually the only provider of such a service, but both are examples of such a service that must be paid for by law.

https://en.wikipedia.org/wiki/Monopsony

Quote

 There are many private plans that provide a supplement to Medicare (like paying your copays and coinsurance for you) that are either purchased or provided as an employee retirement benefit.


You are talking about Part B and Medigap type programs above.

Quote
Generally the only senior citizens that are not enrolled in Medicare are those that live abroad and those that are still working and receive employer-sponsored coverage.

I'm confused.  Are you arguing that Medicare is a natural monopoly?  Or a state-mandated one?

Quote

 The US government also has a pretty strong lock on the market for "defending the US from foreign invasion", and is also a monopoly provider of that service.

I already noted that the US military is, at present, a monopoly provider of national defense services.  But the original claim was that it was so because of of the US Constitution, and
I was challenged to defend such a state monopoly.  It was easy to prove that was not the case, originally.
Every statement you have made with a citation, that I have read, has been either false or so biased that it could not count as a citation (and often still false).  I don't know if that is because of ignorance as forummmm stated or that you are just having fun making shit up.  But not one of your cited statements have been accurate (of a sample size of those I've read).
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 21, 2015, 03:51:57 PM

Every statement you have made with a citation, that I have read, has been either false.  I don't know if that is because of ignorance as forummmm stated or that you are just having fun making shit up.  But not one of your cited statements have been accurate (of a sample size of those I've read).

Heh.  I suppose it's a bit of both.  But if you actually believe that every citation I have presented is actually false; either you haven't read much of mine, or you are more ignorant than I am.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: intellectsucks on August 22, 2015, 09:37:38 AM
Really liking the debate between single payer and private insurance.  Wanted to add a few key points (hopefully the post is not too long….):

The insurance system we have is NOT a capitalistic system.  Insurance regulations are designed so that in each state there are a small number of operators who dominate the market.  The legal barrier for entry is extremely high, so it is unlikely that new operators will enter the market.  Also, operators from one state cannot compete with operators from another state.  While this system also couldn’t be called a socialized system, it is FAR from a capitalist system.

As has been pointed out before, single payer care is a mixed bag.  Some countries, like the oft cited Sweden have fantastic care, but provide that fantastic care in a much smaller, much less densely populated area than the U.S.  They also benefit from much healthier lifestyles, which means that the insurance system is dealing with much different problems.  The U.S. has to deal much more often with chronic issues related to lifestyle (diabetes, vascular and respiratory problems, obesity, lifestyle related cancers, etc) which drives up costs and affects care.  Countries that are closer in size, density, and demographics (such as Canada, the U.K. and France), have great care for minor ailments but sometimes dreadful care for medium to severe ailments.

Single payer can also be a mixed bag within the same country.  If you have a minor ailment (cold, flu, minor infection, broken bone, etc.) the healthcare is usually awesome.  You go to your doctor, urgent care center or hospital, get seen, get treated go home.  Maybe there is a small co-pay, otherwise you pay nothing.  If you have a major ailment that needs multiple visits, tests and treatments, you could run into serious problems with rationing.  Wait lists for things like MRIs, ultrasounds, and non life saving surgery (think hip replacements) can be crushing.  This means that patients have to deal with increased pain and decreased quality of life, but also means that minor issues could progress to major issues before treatment starts.  The U.S. health care system has many problems but wait lists aren’t one of them.  There was a somewhat famous Canadian supreme court decision that declared “access to wait lists is not access to health care” (paraphrased).  

Interestingly, the part of our health care system that is set up most like the single payer systems in places like Canada and the U.K., the Veterans Administration, is having all the same problems with waiting lists, access to care and too few healthcare professionals.  They’re also covering up all their problems to avoid oversight so they can pay giant bonuses to the managers and supervisors who really should be fired.  Waste doesn’t just happen in private insurance companies, however if your insurance company is being wasteful or giving you terrible service, you can go get a new one.  If the only option for insurance is the government, then you’re out of luck.

There was also a discussion of drug prices.  Yes, U.S. pharmaceutical companies are making healthy profits which are a factor in those drug prices.  Those U.S. pharmaceutical companies also account for 36% of new drugs that are released into the market.  Research and development of new drugs is very expensive and the high price tag for new drugs factors in the huge costs associated with developing that drug and other new ones.  A part of the discrepancy between drug prices could be attributed to U.S. patients partially subsidizing the international drug market through higher prices.

Finally the U.S. is ranked among the top, if not THE TOP, when it comes to major ailment survival rates.  If you get cancer, or heart disease or have a heart attack, your treatment and odds of survival are better in the U.S. than almost anywhere else in the world.  This is why for lots of major ailments, you often see “medical tourism” to the U.S. by wealthier foreigners, particularly Canadians.

None of this is to say that the U.S. healthcare system doesn’t have very serious problems, it does.  I’d rank uninsurable people with pre-existing conditions and medical impoverishment as being two of the top ones.  I just don’t see single payer or Obamacare as being the most effective solution to these problems.  The main problems that single payer and Obamacare seek to address is to insure universal Health Insurance coverage and reduce most people’s out of pocket costs.   The reason I don’t think single payer or Obamacare are particularly good for the U.S. is that they mainly address problems that aren’t severe in the U.S. (the vast majority of the uninsured in the U.S. are young, middle class people who could get insurance but choose not to); they also have the potential to make the good things about the U.S. system much worse.

If I had my druthers, I’d like to see the U.S. use a system that goes like this: implement a flat % tax above a certain income limit towards healthcare.  Federalize healthcare regulations (making sure to eliminate lifetime coverage caps and pre-existing condition exclusions) and remove restrictions on buying across state lines.  Have the feds issue a flat payment to the insurance company and allow them to compete based on service and level of coverage.  Allow HSAs on ALL plans to help people be more cost conscious on more routine medical procedures and to offset the cost of copays, drugs, etc.  This would make coverage universal, allow patients much more freedom to choose plans that fit their needs and hopefully lower costs, while at the same time keeping all the good things about our current system.

Further reading on wait times:

http://www.bbc.com/news/uk-wales-25677498

https://en.wikipedia.org/wiki/Chaoulli_v_Quebec_(AG)

http://www.oecd-ilibrary.org/sites/health_glance-2013-en/06/07/index.html?itemId=/content/chapter/health_glance-2013-63-en&mimeType=text/html

Further reading on major illness survival rates:

http://www.webmd.com/cancer/news/20080716/cancer-survival-rates-vary-by-country

http://www.webmd.com/heart-disease/news/20040920/us-tops-canada-in-post-heart-attack-care

Further reading on drug prices:

http://www.nytimes.com/1991/05/24/business/why-drugs-cost-more-in-us.html

https://en.wikipedia.org/wiki/Prescription_drug_prices_in_the_United_States

Further reading on Canadian medical tourism:

http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/18279

http://dailycaller.com/2012/07/11/report-thousands-fled-canada-for-health-care-in-2011/

Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: BCBiker on August 22, 2015, 10:12:17 AM

Interestingly, the part of our health care system that is set up most like the single payer systems in places like Canada and the U.K., the Veterans Administration, is having all the same problems with waiting lists, access to care and too few healthcare professionals.  They’re also covering up all their problems to avoid oversight so they can pay giant bonuses to the managers and supervisors who really should be fired.  Waste doesn’t just happen in private insurance companies, however if your insurance company is being wasteful or giving you terrible service, you can go get a new one.  If the only option for insurance is the government, then you’re out of luck.

The VA is nothing like the single payer in Canada and only marginally similar to UK's system. The VA is paralyzed by it bureaucratic nature where the simple act of hiring a technical employee can take months to years.  This has led to some/many shortfalls in the recent past.  The structure of the organization itself is good and has the potential to provide (and often does) world-class modern care at a decreased cost compared to the private/public mashed up disaster that we call the American Healthcare System. Anyway, I don't think many people who advocate for Single-Payer envision anything that is remotely close to the VA system so trying to combine these two ideas is intellectually dishonest.
 
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Cathy on August 22, 2015, 10:40:30 AM
...Interestingly, the part of our health care system that is set up most like the single payer systems in places like Canada and the U.K. ...

Canada and the UK have entirely different healthcare systems.

For starters, Canada doesn't even have a national healthcare system. Each province has its own legislation governing healthcare. "It would be open to [a province] to adopt a U.S.-style health care system. No one suggests that there is anything ... to prevent it." Chaoulli v. Quebec (Attorney General), 2005 SCC 35 (https://www.canlii.org/en/ca/scc/doc/2005/2005scc35/2005scc35.html), [2005] 1 SCR 791, para 176 (Binnie and LeBel JJ, dissenting but not on this point). The federal government also has a few healthcare programs, but only for certain groups of persons such as military members and federal prisoners.

The Canada Health Act, RSC 1985, c C-6, provides that if a province's healthcare system meets certain criteria, then the federal government will transfer a certain amount of money to that province. Each province is then free to implement legislation to satisfy those requirements however it wants (or not at all), discussed in a previous post (http://forum.mrmoneymustache.com/post-fire/supreme-court-challenge-to-the-aca/msg717595/#msg717595). Similar financial incentive schemes exist in the US.

Currently, every province has a fairly similar healthcare system (although they are not required to), but even then there are notable differences. In Alberta, the general system is that all or almost all healthcare is provided by private physicians and other private professionals (not by the government), but those professionals are limited in what they can charge by a system of legislatively-authorised price controls under the Alberta Health Care Insurance Act, RSA 2000, c A-20, described in a different previous post (http://forum.mrmoneymustache.com/taxes/fairtax-flat-tax-comments/msg769140/#msg769140).

...There was a somewhat famous Canadian supreme court decision that declared “access to wait lists is not access to health care” (paraphrased)...

The case you are thinking of is Chaoulli, supra, which was a challenge to certain aspects of Quebec's healthcare system. The decision found that Quebec's healthcare legislation was in part invalid because it obstructed reasonable access to healthcare, among other reasons. The decision did not consider the validity of any federal legislation or the legislation of any other province. All of the discussion and evidence and legal analysis was specifically about Quebec's healthcare system, except when the Court discussed how Quebec's system differed from other provinces and other countries.


A nuanced discussion of healthcare cannot treat every system outside the US as if they were all the same system. "There is no single model; the approach in Europe is no more uniform than in Canada." Chaoulli, para 77. I personally think the major characteristic of the Canadian system (to the extent a Canadian system exists) is price controls, which are a major component of the healthcare system in every province, and likely a big part of the reason that healthcare is relatively inexpensive throughout Canada.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: intellectsucks on August 22, 2015, 11:30:25 AM
Wasn’t trying to be intellectually dishonest.  It does seem that the UK and Canadian systems have far more in common with the VA than you make it seem.

If I’m understanding things correctly in all three systems, they are funded by tax dollars, medical workers are government employees or contractors and hospitals and doctors offices are owned by the government.  If you are saying that the VA’s method of implementing that system means that it is not comparable I’d have to respectfully disagree.  Regardless of hiring practices or bureaucracy, single payer systems have more in common with each other than more capitalist based systems.  The VA is also an important example because it highlights the unique nature of challenges that single payer would face in the US.  

People who want single payer in the US want the care that the VA should be providing ALL the time: affordable, reliable, world class care with little to no cost to patients.  The problem these people don’t address is how to avoid the very real problems the VA has: bureaucracy, fraud, and resistance to change.  I don’t believe that we can avoid those problems with single payer healthcare in the U.S.

quote author=BCBiker link=topic=39883.msg778259#msg778259 date=1440259937]

Interestingly, the part of our health care system that is set up most like the single payer systems in places like Canada and the U.K., the Veterans Administration, is having all the same problems with waiting lists, access to care and too few healthcare professionals.  They’re also covering up all their problems to avoid oversight so they can pay giant bonuses to the managers and supervisors who really should be fired.  Waste doesn’t just happen in private insurance companies, however if your insurance company is being wasteful or giving you terrible service, you can go get a new one.  If the only option for insurance is the government, then you’re out of luck.

The VA is nothing like the single payer in Canada and only marginally similar to UK's system. The VA is paralyzed by it bureaucratic nature where the simple act of hiring a technical employee can take months to years.  This has led to some/many shortfalls in the recent past.  The structure of the organization itself is good and has the potential to provide (and often does) world-class modern care at a decreased cost compared to the private/public mashed up disaster that we call the American Healthcare System. Anyway, I don't think many people who advocate for Single-Payer envision anything that is remotely close to the VA system so trying to combine these two ideas is intellectually dishonest.
[/quote]
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: intellectsucks on August 22, 2015, 12:03:25 PM
Cathy, thanks for the clarification. I still do not feel that having single payer implemented by states or provinces distinguishes it enough from single payer implemented by a federal government, neither does having physicians employed by the government vs being paid per service by the government. The nearly universal problem with single payer systems is wait times and care rationing.  I feel that the problems of the U.S. health system can be addressed in ways that will not adopt the problems of a single payer system.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 27, 2015, 10:02:49 PM
I was listening to the latest podcast from Freakanomics Radio, called Are you ready for a Glorious Sunset?.  I quickly realized it's relevant to the last several debates in this thread.  It's worth the time to listen to, as most of the Freakanomics Radio podcasts are.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Sibley on August 28, 2015, 10:04:56 AM
Since I'm still in the part where everyone is bashing Medicaid... I work in the health insurance industry. We have a saying: If you've seen one Medicaid program, you've seen one Medicaid program.

The Federal government sets out some guidelines, but each state has a lot of room to decide what they want to cover. No two states are exactly alike. None are perfect. All have pros and cons. In my view, something is better than nothing however.

Also, in case you're curious, we already have a non-universal single-payer system. It's called Medicare, and it covers a big chunk of the population (I don't have time to find the exact numbers right now, sorry).

For those who like data, check out the Annual Statistical Supplement. 2015 isn't complete yet, but here's the link to 2014:
https://www.socialsecurity.gov/policy/docs/statcomps/supplement/
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 28, 2015, 10:51:04 AM
Since I'm still in the part where everyone is bashing Medicaid... I work in the health insurance industry. We have a saying: If you've seen one Medicaid program, you've seen one Medicaid program.

The Federal government sets out some guidelines, but each state has a lot of room to decide what they want to cover. No two states are exactly alike. None are perfect. All have pros and cons. In my view, something is better than nothing however.

Also, in case you're curious, we already have a non-universal single-payer system. It's called Medicare, and it covers a big chunk of the population (I don't have time to find the exact numbers right now, sorry).

For those who like data, check out the Annual Statistical Supplement. 2015 isn't complete yet, but here's the link to 2014:
https://www.socialsecurity.gov/policy/docs/statcomps/supplement/

Medicare covers about 1/6 people in the US. Between all public sources (CHIP, Medicaid, Tricare, etc) it's about 1/3.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Sibley on August 28, 2015, 02:01:45 PM
Since I'm still in the part where everyone is bashing Medicaid... I work in the health insurance industry. We have a saying: If you've seen one Medicaid program, you've seen one Medicaid program.

The Federal government sets out some guidelines, but each state has a lot of room to decide what they want to cover. No two states are exactly alike. None are perfect. All have pros and cons. In my view, something is better than nothing however.

Also, in case you're curious, we already have a non-universal single-payer system. It's called Medicare, and it covers a big chunk of the population (I don't have time to find the exact numbers right now, sorry).

For those who like data, check out the Annual Statistical Supplement. 2015 isn't complete yet, but here's the link to 2014:
https://www.socialsecurity.gov/policy/docs/statcomps/supplement/

Medicare covers about 1/6 people in the US. Between all public sources (CHIP, Medicaid, Tricare, etc) it's about 1/3.

Thanks forummm!
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: TheDudeReturns on August 30, 2015, 06:27:15 AM
Guess I need to pop back into my own thread. Had no idea it would be so popular; I attribute that to a nice thread title :)

Anyway, all this philosophical talk is all well and good, but honestly, like most politics-based discussion, there's nothing really actionable to all of it. It's just another bread and circus, albeit for people who want to argue about actuarial tables and macroeconomics.

At it's core, Obamacare is just a complex way to raise more money for a broke government. Yeah, not excluding preexisting conditions is nice, but it looks like costs and complexity have risen to wash away any benefits to the rest of us. It also takes advantage of the stupid, mainly college students. A lot of schools are automatically charging students for health insurance and then it's the student's job to prove they have insurance already and opt-out before the deadline. The prices I've seen on these plans (which are capped at $100k in lifetime benefits) are about $2k-$3k for the whole year, but hey, you can use student loan monopoly money to pay for them, so why worry! :)

Anyway, I'm just a nobody reacting to the machinations of the leviathan, so I just want to make a good choice on this crap. I forgot some money made earlier in the year, so it looks like I'll be getting a bronze or silver plan. I hear the bronze plan with a HSA is the way to go (can't wait to "save" my money in some junky mutual funds in there!). However, with the subsidy (government gravy) it looks like it's about a $100 a month difference between the bronze and silver HSA. The silver HSA has a mega low deductible at the moment, but that looks to go away at relatively low income levels, so I'm not sure if it's worth getting used to that now.

Do most of you mustaches go with the cheapest bronze HSA you can? Nice to always get insurance that doesn't cover anything :)

Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: forummm on August 30, 2015, 07:32:23 AM
Guess I need to pop back into my own thread. Had no idea it would be so popular; I attribute that to a nice thread title :)

Anyway, all this philosophical talk is all well and good, but honestly, like most politics-based discussion, there's nothing really actionable to all of it. It's just another bread and circus, albeit for people who want to argue about actuarial tables and macroeconomics.

At it's core, Obamacare is just a complex way to raise more money for a broke government. Yeah, not excluding preexisting conditions is nice, but it looks like costs and complexity have risen to wash away any benefits to the rest of us. It also takes advantage of the stupid, mainly college students. A lot of schools are automatically charging students for health insurance and then it's the student's job to prove they have insurance already and opt-out before the deadline. The prices I've seen on these plans (which are capped at $100k in lifetime benefits) are about $2k-$3k for the whole year, but hey, you can use student loan monopoly money to pay for them, so why worry! :)

Anyway, I'm just a nobody reacting to the machinations of the leviathan, so I just want to make a good choice on this crap. I forgot some money made earlier in the year, so it looks like I'll be getting a bronze or silver plan. I hear the bronze plan with a HSA is the way to go (can't wait to "save" my money in some junky mutual funds in there!). However, with the subsidy (government gravy) it looks like it's about a $100 a month difference between the bronze and silver HSA. The silver HSA has a mega low deductible at the moment, but that looks to go away at relatively low income levels, so I'm not sure if it's worth getting used to that now.

Do most of you mustaches go with the cheapest bronze HSA you can? Nice to always get insurance that doesn't cover anything :)

I think like most people you don't understand the system and misattribute one effect to an entirely different cause. It's complicated, so I get why someone would do that. The ACA is only slightly revenue positive. It's intent was to improve access to health insurance, not improve the budget (although it does that slightly too). And everyone benefits from improved protections like pre-existing conditions and rescision and guaranteed issue. You don't realize how much you benefit from them because you haven't needed them yet--it's insurance, it's there for when you do need it. Universities have been requiring their students to have health insurance, and making the student plan the default for decades before anyone had heard of Obama. Those policies aren't even ACA-compliant. An ACA plan would be a better deal for the students in many cases.

A bronze plan does cover stuff. The deductibles are lower than for my house, the premiums are in that ballpark too, and much more expensive stuff can happen to a person than a house. It's insurance. Hopefully you don't need it, but you're paying for the "in case" part of it. For plans with no deductible and low copays private employers have to pay almost $10k per person for those. Healthcare is stupidly expensive.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Gin1984 on August 30, 2015, 08:34:49 AM
Guess I need to pop back into my own thread. Had no idea it would be so popular; I attribute that to a nice thread title :)

Anyway, all this philosophical talk is all well and good, but honestly, like most politics-based discussion, there's nothing really actionable to all of it. It's just another bread and circus, albeit for people who want to argue about actuarial tables and macroeconomics.

At it's core, Obamacare is just a complex way to raise more money for a broke government. Yeah, not excluding preexisting conditions is nice, but it looks like costs and complexity have risen to wash away any benefits to the rest of us. It also takes advantage of the stupid, mainly college students. A lot of schools are automatically charging students for health insurance and then it's the student's job to prove they have insurance already and opt-out before the deadline. The prices I've seen on these plans (which are capped at $100k in lifetime benefits) are about $2k-$3k for the whole year, but hey, you can use student loan monopoly money to pay for them, so why worry! :)

Anyway, I'm just a nobody reacting to the machinations of the leviathan, so I just want to make a good choice on this crap. I forgot some money made earlier in the year, so it looks like I'll be getting a bronze or silver plan. I hear the bronze plan with a HSA is the way to go (can't wait to "save" my money in some junky mutual funds in there!). However, with the subsidy (government gravy) it looks like it's about a $100 a month difference between the bronze and silver HSA. The silver HSA has a mega low deductible at the moment, but that looks to go away at relatively low income levels, so I'm not sure if it's worth getting used to that now.

Do most of you mustaches go with the cheapest bronze HSA you can? Nice to always get insurance that doesn't cover anything :)
Speaking as someone who was on COBRA prior to ACA because I could not find ANY insurance because I made messed up my back, that covering pre-existing conditions is more than nice.  It is amazing.  It also allowed my mom to retire three years earlier than she had planned because now she can have health insurance.  And on that note, the cost of an ACA plan in both NY and Ca is about the same (or cheaper) than COBRA that I and my mom paid so no, it has not increased.  And, it does not take advantage of students.  It is a quick form, they let you know that you have an option of either AND they did it prior to ACA as well so not the fault of the ACA.  And to speak to the bronze plan, it covers way more than many plans prior to the ACA.  I use a HSA plan myself as many people do here, it is great additional retirement savings.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Cassie on August 30, 2015, 01:22:09 PM
I really wish we had went to a single payor like Medicare for everyone with affordable premiums & some of the cost included in taxes so the more people make the more they pay into the system.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Hamster on August 31, 2015, 12:47:39 AM
You don't realize how much you benefit from them because you haven't needed them yet--it's insurance, it's there for when you do need it...

Not to harp on this, but "health insurance" is to a VERY large part actually not insurance. The part of your plan that covers preventive care is not insurance, it is a negotiated payment plan, or a guarantee of benefits which you are prepaying for whether you use them or not. In that sense it's more like a Netflix subscription than insurance. You pay ahead. If you didn't use it, you don't get it back.

Lumping insurance with routine medical expenses is part of the reasons premiums are so high. It eliminates price transparency and price competition for routine care.


Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: TheDudeReturns on August 31, 2015, 02:21:15 AM
You don't realize how much you benefit from them because you haven't needed them yet--it's insurance, it's there for when you do need it...

Not to harp on this, but "health insurance" is to a VERY large part actually not insurance. The part of your plan that covers preventive care is not insurance, it is a negotiated payment plan, or a guarantee of benefits which you are prepaying for whether you use them or not. In that sense it's more like a Netflix subscription than insurance. You pay ahead. If you didn't use it, you don't get it back.

Lumping insurance with routine medical expenses is part of the reasons premiums are so high. It eliminates price transparency and price competition for routine care.

Someone who gets it. Aside from federal dollars entering the industry and pushing prices and inefficiencies higher (just look at the higher education sector), people who don't want to pay $100-$200 out of pocket to visit a doctor or *gasp* buy birth control (kids are more expensive) makes things more expensive for everyone.

When you need to change your taillight, you don't turn that into your auto insurance. Going to the doctor and getting feeled up for preventive checks is sort of the same thing.

Anyway, my questions were never answered, which is what I saw on several other "But I don't want Medicaid..." style posts online; the conversation just descended in politics on here just like on those.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: goatmom on August 31, 2015, 04:35:23 AM
As someone who has experienced VA healthcare, I would not want to have to choose it.  Luckily, I have other options.  I like being able to select my own doctor.  At the VA, you are assigned one.  There is frequent turnover in doctors. Try getting a hold of anyone after hours.  If you are receiving mental health services be prepared to have a new therapist every few month and have to start all over.  And if you are anywhere other than a major city, the mental health is via telemedicine.  Now - the pharmacy benefits are great.  Free is good.  But not good enough to make me deal with it.  I like to pick a doctor I like and have some continuity esp in mental health issues.  It's worth paying something out of pocket for to me.  I know others aren't fortunate enough to have those options. If that is what single payer looks like - no thank  you.  I think there has to be a better solution.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: sol on August 31, 2015, 05:38:38 AM
I suspect that at least some of the problems with the VA are because the provider network and patient pool are both limited.  Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Currently, healthcare providers are divided up into groups.  You're might have an hmo out a ppo, each with a different network of providers.  Under single payer there would by definition be one network. Think how many of the above problems would be solved.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: ShoulderThingThatGoesUp on August 31, 2015, 05:53:39 AM
Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Because...magic?
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Gin1984 on August 31, 2015, 06:43:52 AM
Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Because...magic?
Because they can't leave one provider for another.  For example, my Kaiser doctor left Kaiser for a private practice.  If there was one provider plan, I could have followed her.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: asiljoy on August 31, 2015, 06:50:48 AM
You don't realize how much you benefit from them because you haven't needed them yet--it's insurance, it's there for when you do need it...

Not to harp on this, but "health insurance" is to a VERY large part actually not insurance. The part of your plan that covers preventive care is not insurance, it is a negotiated payment plan, or a guarantee of benefits which you are prepaying for whether you use them or not. In that sense it's more like a Netflix subscription than insurance. You pay ahead. If you didn't use it, you don't get it back.

Lumping insurance with routine medical expenses is part of the reasons premiums are so high. It eliminates price transparency and price competition for routine care.

No actually. The insurance companies want you to get your routine care. It drastically lowers costs for them by treating issues when they're small versus waiting until they're chronic diseases. For example, let's get that weight under control by dieting before you end up with diabetes and a heart condition.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: ShoulderThingThatGoesUp on August 31, 2015, 07:28:49 AM
Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Because...magic?
Because they can't leave one provider for another.  For example, my Kaiser doctor left Kaiser for a private practice.  If there was one provider plan, I could have followed her.

The turnover part I get, but the rationing part, not so much.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: monstermonster on August 31, 2015, 09:31:42 AM
Yeah, not excluding preexisting conditions is nice, but it looks like costs and complexity have risen to wash away any benefits to the rest of us

It's painful to watch you attack the pre-existing condition coverage as though it's just for "other people". You've clearly never been affected by it - but ask around. I guarantee at least 1/3 of the people you know were denied coverage or had coverage that didn't cover the thing they needed most because of this ridiculous restriction, which does not exist in ANY OTHER healthcare market in the world.

I feel so privileged that thanks to the ACA, I was able to seek and get treatment for my pre-existing condition on my newly-acquired health insurance. Starting at 18 years old, I could NOT get coverage for my autoimmune disorder and had 10 years of not being able to seek treatment while my joints got worse and worse. I'm a former internationally competitive athlete who got to the point she couldn't open doorknobs by herself. Why? Because I couldn't get any treatment for a DECADE because of this claus. Since the ACA kicked in and I got covered (at first by Medicaid- which is just private insurance in my state- because my 5 different contract jobs did not cover health insurance, of course, when you live in poverty you don't expect to have things like medical insurance.) I feel so privileged to have health insurance (now private through work at the exact same HMO as Medicaid was) that pays for this $2800/month drug that has changed my life. I can swing on trapeze and run half-marathons now. I'm symptom-free, working 60-70 hours/week, and now there's little chance I'll have to go on disability, which is common for people with my disorder. Why? Because of Obamacare. This is just ONE story.

Ask around, and you'll realize that the statistical possibility that you would have been affected by this clause at some point in your life was very high. Less likely if you're male, but if you're female, the chance of being denied health insurance for all the workers in your small business because you had a yeast infection at SOME POINT in your life or because you had a complicated pregnancy meant that you not only couldn't get health insurance, your employees couldn't, and in many places it was likely you couldn't even find a provider you could pay out of pocket.
It also takes advantage of the stupid, mainly college students. A lot of schools are automatically charging students for health insurance and then it's the student's job to prove they have insurance already and opt-out before the deadline. The prices I've seen on these plans (which are capped at $100k in lifetime benefits) are about $2k-$3k for the whole year, but hey, you can use student loan monopoly money to pay for them, so why worry! :)

The thing to note was that the ACA made it possible for most of those college students to be covered under their parent's plans until they are 26 years old (regardless of student status). Previously that was a thing they "might" have on certain plans, and the insurance companies would put all sorts of restrictions about credit load status, putting them in the business of verifying that you're taking 12 credits instead of worrying about healthcare like they should. And if you lost coverage after you stopped being enrolled in college, at the age of 22, you could find yourself now with non-continuous coverage and therefore saddled with a pre-existing condition. So as a 22-year old, you might not be able to get your own insurance OR at the very least you might not get coverage for your diabetes.

OR perhaps your parents coverage doesn't cover you, so you go without health insurance. Then guess what? You get in a car crash. Or suffer a traumatic brain injury while playing college sports. Or slip and fall on ice. Well, that 50K in student loan debt looks a lot better than that 200K of medical debt you just took on for one hospital spill. At least requiring catastrophic coverage prevents that.

I broke my wrist my last year of college,  5 months after I started getting coverage due to the ACA. I would have been $28K in debt if it weren't for the ACA. That's more than I made the next 2 years combined. Thanks to insurance, I just had to scrimp and save and work 3 jobs while finishing my thesis so I could pay off the $3,000 I owed for insurance.

Do not even try to pretend the ACA didn't change lives for the better. It has its problems, I agree. But it has CHANGED LIVES immeasurably. And only due to luck and a dose of privilege that this change is not in yours.

Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Hamster on August 31, 2015, 09:58:33 AM
You don't realize how much you benefit from them because you haven't needed them yet--it's insurance, it's there for when you do need it...
...
Lumping insurance with routine medical expenses is part of the reasons premiums are so high. It eliminates price transparency and price competition for routine care.

No actually. The insurance companies want you to get your routine care. It drastically lowers costs for them by treating issues when they're small versus waiting until they're chronic diseases. For example, let's get that weight under control by dieting before you end up with diabetes and a heart condition.

Sort of... This is a myth to a large extent. While detecting disease early and intervening early can be less costly, there is a large amount of preventive care we do that has never been shown to be cost effective. As a pediatrician, I really like my patients to come in for their scheduled well-child exams because I think it is good medicine and a good way to know my patients. As for it reducing costs in any way... not so much.

Probably the only part of it that actually reduces actual dollar costs of healthcare is the immunizations, and those could be done at a nurse-only clinic, or even a pharmacy. Wouldn't be as good care, but would be cost-effective.

As for insurance wanting to pay for preventive care. There were a ton of standard preventive services (e.g. in kids - vision and hearing screening, developmental screening, etc) that many insurers refused to pay for until mandated by Obamacare. If insurers really believed this care saved money, they would have been happy to promote it. There are plenty of adult examples as well.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Gin1984 on August 31, 2015, 10:01:23 AM
You don't realize how much you benefit from them because you haven't needed them yet--it's insurance, it's there for when you do need it...
...
Lumping insurance with routine medical expenses is part of the reasons premiums are so high. It eliminates price transparency and price competition for routine care.

No actually. The insurance companies want you to get your routine care. It drastically lowers costs for them by treating issues when they're small versus waiting until they're chronic diseases. For example, let's get that weight under control by dieting before you end up with diabetes and a heart condition.

Sort of... This is a myth to a large extent. While detecting disease early and intervening early can be less costly, there is a large amount of preventive care we do that has never been shown to be cost effective. As a pediatrician, I really like my patients to come in for their scheduled well-child exams because I think it is good medicine and a good way to know my patients. As for it reducing costs in any way... not so much.

Probably the only part of it that actually reduces actual dollar costs of healthcare is the immunizations, and those could be done at a nurse-only clinic, or even a pharmacy. Wouldn't be as good care, but would be cost-effective.

As for insurance wanting to pay for preventive care. There were a ton of standard preventive services (e.g. in kids - vision and hearing screening, developmental screening, etc) that many insurers refused to pay for until mandated by Obamacare. If insurers really believed this care saved money, they would have been happy to promote it. There are plenty of adult examples as well.
Birth control at $50/month is cheaper than one pregnancy.  Many insurance companies did not want to cover birth control but their reasons were not completely fiscal.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 31, 2015, 11:51:45 AM
I suspect that at least some of the problems with the VA are because the provider network and patient pool are both limited. Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Except that's not entirely true, if you think about it.  There already exist concierge doctors, which have served the very wealthy for a very long time, who don't bother with the whole third-party payer insurance model at all.  This aspect of the medical profession has grown from a nominally non-existent minority of services; to a small minority of services, particularly since the ACA.  These types of practices have become common enough that upper middle class people, and particularly seniors, can get into these practices as patients; with real benefits for themselves.  This is just one near me... http://louisvilleconciergemedicine.com/

So it's not entirely true that medical providers must participate in a single payer system, and taken to an extreme, the very highest quality health care may no longer be accessible to the poor and lower middle class for any price under a single payer form of health care.  Granted, this form of completely privately funded health care exists pretty much everywhere on Earth, and hasn't grown to any significant degree in European nations with socialized health care; but as I have pointed out before, Europe is not the US.  Concierge has provably grown a significant amount just since the ACA passed, and it's not even single payer.  Just the electronic health records mandates many people find offensive, but only the wealthy have found such a complete degree of medical privacy to be worth the cost until recently.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Gin1984 on August 31, 2015, 11:57:54 AM
I suspect that at least some of the problems with the VA are because the provider network and patient pool are both limited. Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Except that's not entirely true, if you think about it.  There already exist concierge doctors, which have served the very wealthy for a very long time, who don't bother with the whole third-party payer insurance model at all.  This aspect of the medical profession has grown from a nominally non-existent minority of services; to a small minority of services, particularly since the ACA.  These types of practices have become common enough that upper middle class people, and particularly seniors, can get into these practices as patients; with real benefits for themselves.  This is just one near me... http://louisvilleconciergemedicine.com/

So it's not entirely true that medical providers must participate in a single payer system, and taken to an extreme, the very highest quality health care may no longer be accessible to the poor and lower middle class for any price under a single payer form of health care.  Granted, this form of completely privately funded health care exists pretty much everywhere on Earth, and hasn't grown to any significant degree in European nations with socialized health care; but as I have pointed out before, Europe is not the US.  Concierge has provably grown a significant amount just since the ACA passed, and it's not even single payer. Just the electronic health records mandates many people find offensive, but only the wealthy have found such a complete degree of medical privacy to be worth the cost until recently.
Your link includes this line "We kindly ask you to bring your insurance cards and copay (if applicable) to each visit." so how exactly are they taking insurance?
And secondly, the  electronic medical records requirement is for medicare and medicaid, nothing else so a doctor's office can avoid using EMR if they chose, most do not.  Many people were upset not because of lack of privacy but because of ignorance.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 31, 2015, 01:01:18 PM
I suspect that at least some of the problems with the VA are because the provider network and patient pool are both limited. Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Except that's not entirely true, if you think about it.  There already exist concierge doctors, which have served the very wealthy for a very long time, who don't bother with the whole third-party payer insurance model at all.  This aspect of the medical profession has grown from a nominally non-existent minority of services; to a small minority of services, particularly since the ACA.  These types of practices have become common enough that upper middle class people, and particularly seniors, can get into these practices as patients; with real benefits for themselves.  This is just one near me... http://louisvilleconciergemedicine.com/

So it's not entirely true that medical providers must participate in a single payer system, and taken to an extreme, the very highest quality health care may no longer be accessible to the poor and lower middle class for any price under a single payer form of health care.  Granted, this form of completely privately funded health care exists pretty much everywhere on Earth, and hasn't grown to any significant degree in European nations with socialized health care; but as I have pointed out before, Europe is not the US.  Concierge has provably grown a significant amount just since the ACA passed, and it's not even single payer. Just the electronic health records mandates many people find offensive, but only the wealthy have found such a complete degree of medical privacy to be worth the cost until recently.
Your link includes this line "We kindly ask you to bring your insurance cards and copay (if applicable) to each visit." so how exactly are they taking insurance?

The difference is that a concierge office typically charges a membership fee, not that they won't take insurance payouts.  A typical concierge office will not engage into a payment network that dictates how much they can charge, however, so medicare is probably off the table.

Quote


And secondly, the  electronic medical records requirement is for medicare and medicaid, nothing else so a doctor's office can avoid using EMR if they chose, most do not.  Many people were upset not because of lack of privacy but because of ignorance.

That may be true, but there must be other reasons that they can't avoid the electronic records mandates, because I know that even my kids' pediatrician's office is aggravated with the e-records thing, and I know they don't take either medicare or medicaid.  They don't even take the state version of medicaid for children.  I think that it's more of a medical business network thing; other offices inside their business network are forced into it, so either they participate with the rest of the business network, or they leave the network.  Collective maintainence of office software cannot be the major advantages of these medical business networks, although I don't know what the compelling reasons may be.

But the key point that I was making was that concierge offices don't have to abide any of this crap, and there is an apparently growing minority of patients that are willing to pay for their care in this manner; even when it's more expensive.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: Gin1984 on August 31, 2015, 01:07:45 PM
I suspect that at least some of the problems with the VA are because the provider network and patient pool are both limited. Under a single payer system, where every healthcare provider was included because there was no longer any other option, I think you would see fewer problems with turnover and rationing.

Except that's not entirely true, if you think about it.  There already exist concierge doctors, which have served the very wealthy for a very long time, who don't bother with the whole third-party payer insurance model at all.  This aspect of the medical profession has grown from a nominally non-existent minority of services; to a small minority of services, particularly since the ACA.  These types of practices have become common enough that upper middle class people, and particularly seniors, can get into these practices as patients; with real benefits for themselves.  This is just one near me... http://louisvilleconciergemedicine.com/

So it's not entirely true that medical providers must participate in a single payer system, and taken to an extreme, the very highest quality health care may no longer be accessible to the poor and lower middle class for any price under a single payer form of health care.  Granted, this form of completely privately funded health care exists pretty much everywhere on Earth, and hasn't grown to any significant degree in European nations with socialized health care; but as I have pointed out before, Europe is not the US.  Concierge has provably grown a significant amount just since the ACA passed, and it's not even single payer. Just the electronic health records mandates many people find offensive, but only the wealthy have found such a complete degree of medical privacy to be worth the cost until recently.
Your link includes this line "We kindly ask you to bring your insurance cards and copay (if applicable) to each visit." so how exactly are they taking insurance?

The difference is that a concierge office typically charges a membership fee, not that they won't take insurance payouts.  A typical concierge office will not engage into a payment network that dictates how much they can charge, however, so medicare is probably off the table.

Quote


And secondly, the  electronic medical records requirement is for medicare and medicaid, nothing else so a doctor's office can avoid using EMR if they chose, most do not.  Many people were upset not because of lack of privacy but because of ignorance.

That may be true, but there must be other reasons that they can't avoid the electronic records mandates, because I know that even my kids' pediatrician's office is aggravated with the e-records thing, and I know they don't take either medicare or medicaid.  They don't even take the state version of medicaid for children.  I think that it's more of a medical business network thing; other offices inside their business network are forced into it, so either they participate with the rest of the business network, or they leave the network.  Collective maintainence of office software cannot be the major advantages of these medical business networks, although I don't know what the compelling reasons may be.

But the key point that I was making was that concierge offices don't have to abide any of this crap, and there is an apparently growing minority of patients that are willing to pay for their care in this manner; even when it's more expensive.
Except your example case DOES take medicare patients and therefore they DO have to "abide any of this crap".  The difference is you pay for a greater access to your MDs time in a concierge office vs using NP or PAs, or training MDs.  Which is not your central argument in this regard and therefore has nothing to do with the debate.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: MoonShadow on August 31, 2015, 03:18:55 PM

Except your example case DOES take medicare patients and therefore they DO have to "abide any of this crap".  The difference is you pay for a greater access to your MDs time in a concierge office vs using NP or PAs, or training MDs.  Which is not your central argument in this regard and therefore has nothing to do with the debate.

Well, I just grabbed that link from a quick google search, so it may not be the best example of what I'm trying to say.  Regardless, I guess we are just going to have to disagree.  It certainly appears to me that something in the ACA is promoting concierge medical offices, even if my assumptions that it was related to the e-records requirements is incorrect.
Title: Re: Obamacare Blues: But I don't want Medicaid...
Post by: goatmom on August 31, 2015, 08:51:07 PM
How would every doctor be included in a single payer system?  Not exactly sure how this works.  I know in some other countries that have single payer - there are still two tiers of healthcare - public and private.  Doctors can choose not to participate and just take private patients.  People will then pay out of pocket for this if they perceive the care is better. 

As for the electronic medical records, some states are moving toward requiring electronic prescribing.  Next year in New York paper prescriptions will be all but extinct.  Many of the eprescribing programs are part of larger EMR.