Author Topic: What comes after the ACA?  (Read 951867 times)

seattlecyclone

  • Magnum Stache
  • ******
  • Posts: 4730
  • Age: 34
  • Location: Seattle, WA
Re: What comes after the ACA?
« Reply #5250 on: January 03, 2019, 10:04:19 AM »
I think transparency is a good thing, of course, but I don't see this particular change doing much to lower costs.  As has been pointed out, the vast majority of health care transactions are between the provider and an insurer, and they negotiate their prices outside the chargemaster.

Exactly. I think real price transparency could be a rather powerful thing, but this is not that. The chargemaster is basically a book of made-up ridiculous prices that they use to begin the negotiation with the few poor saps who come in for care without (in-network) insurance. To get useful information, we'll not only need to see the chargemaster price for a particular service, but also the rate negotiated with insurance companies, because those are the real prices that are charged in the majority of circumstances.

Quote
In my opinion, a much more consequential change would be eliminating the ACA requirement that insurance companies spend 80% of the money they collect on care, and use the other 20% for all of their costs (including their profit).  While the rule was well-intentioned, it takes away the insurance company's incentive to negotiate lower prices, because they have to refund the savings to consumers instead of keeping it to boost their profits.  On the other hand, if the providers raise their prices and the insurer has to pay out more than 80% of their revenue, the insurer can raise its prices to keep up.  And it gets to keep 20% of the higher price.  So the only way they get to make more money is to increase their total revenue, which can only be done by letting providers raise their prices.  Seems like a textbook case of unintended consequences. 

Yeah I've been saying this for a while. Our system as it stands now has basically nobody with incentive to keep prices down.

Providers of course have every incentive to maximize their revenue.

Insurance companies only care a little bit about negotiating rates. They have to pass their costs along to their customers in the form of premiums, so if their negotiated prices for services are way out of line with what the other companies are paying they're going to lose customers. However if every insurer is able to negotiate roughly the same price increase every year, they get to pocket 20% of the increase.

Patients sometimes have incentive to care about prices in cases where care can be planned in advance and they aren't close to meeting their deductible. Good luck getting a provider to provide a cost estimate in advance that takes your insurance carrier into account though. About the best that most folks can do is find someone in network and hope for the best. Once the deductible is satisfied, a patient might only be paying a small fraction of the cost out of pocket, making any effort to comparison shop be much less worthwhile.

Aelias

  • Bristles
  • ***
  • Posts: 286
Re: What comes after the ACA?
« Reply #5251 on: January 03, 2019, 10:50:32 AM »

I understand your frustration, but it's best not to think of insurers as people, you just need to embrace the clinical detachment when interacting with them. By all means be nice to their reps, but to the machine you're just a number spitting out a bunch of claim codes at semi-random intervals. They couldn't care less whether someone touched your pussy or your big toe, it's all codes and procedures to them. They've seen it all.

I appreciate the understanding.  I'm most frustrated by the fact that I would have to seek preapproval for such a routine procedure.  If I were on the pill and wanted to switch to a different one or stop taking it altogether, I can't imagine I'd need "preapproval" for that.

In a week or so, I'll probably be able to laugh at the absurdity of it all and approach it with the clinical detachment that helps keep this insanity in the proper perspective.  But there are just no good encounters to be had with a health insurance company.  Ever.  It's all frustration. 

I don't necessarily know what the better way is, but there has got to be a better way.

Bucksandreds

  • Pencil Stache
  • ****
  • Posts: 802
Re: What comes after the ACA?
« Reply #5252 on: January 03, 2019, 11:10:15 AM »

 

I don't necessarily know what the better way is, but there has got to be a better way.
Considering we rank last in just about every satisfaction survey, I'm not sure it matters what we switched to. The UKs combo of national health system with private options for consumers who desire it, ranked #1 and cost less than half ours per capita (Hint a public option for necessary procedures lowers the price that private providers can get away with charging.) That gets you the same quality and options at a fraction of the cost. it's not rocket science. It's people with their hand in the status quo cookie jar sowing seeds of doubt.

https://www.cbsnews.com/news/u-s-health-care-system-ranks-lowest-in-international-survey/

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 5989
  • Age: 57
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: What comes after the ACA?
« Reply #5253 on: January 03, 2019, 12:14:44 PM »

 

I don't necessarily know what the better way is, but there has got to be a better way.
Considering we rank last in just about every satisfaction survey, I'm not sure it matters what we switched to. The UKs combo of national health system with private options for consumers who desire it, ranked #1 and cost less than half ours per capita (Hint a public option for necessary procedures lowers the price that private providers can get away with charging.) That gets you the same quality and options at a fraction of the cost. it's not rocket science. It's people with their hand in the status quo cookie jar sowing seeds of doubt.

https://www.cbsnews.com/news/u-s-health-care-system-ranks-lowest-in-international-survey/

But at least we don't have a socialist HC system.. so thats the main thing right?

pecunia

  • Pencil Stache
  • ****
  • Posts: 946
Re: What comes after the ACA?
« Reply #5254 on: January 03, 2019, 02:04:57 PM »

- CUT -

But at least we don't have a socialist HC system.. so thats the main thing right?

You've got a good point there.  When I was growing up I heard a lot of tales of the evil commies and that our military was doing it's patriotic duty for mom and apple pie.  It wasn't stated explicitly, but the US was defending free enterprise as well.  Sometimes, they'd give an example of Uncle Wilbur and his barber shop.  It was stated that Uncle Wilbur would not be able to open his barber shop across the iron curtain.  None of the mom and pop stores would exist on Main Street.

Today, we face a different fight with a different type of soldier.  The soldier of today is the patient who serves the  American healthcare system.  Some may call it overpriced medicine, but others call it a capitalistic opportunity.  Every patient today enriches the healthcare system and is an example of successful capitalism.  Some may not be able to afford the health care system and die.  These patients are like brave soldiers who give their lives in support of our capitalist healthcare system.

America may be the last example of such a pure capitalist system.  The mom and pop stores have closed due to Wal Mart.  We have to save what is left. This system will be defended to the last red drop of every American patient's blood.  We have the finest healthcare system in the world for investors and we should all be proud. 

Please face the flag and join me in reciting the Pledge of Allegiance.  The Eagle has Landed!

DreamFIRE

  • Handlebar Stache
  • *****
  • Posts: 1596
Re: What comes after the ACA?
« Reply #5255 on: January 03, 2019, 03:54:15 PM »

- CUT -

But at least we don't have a socialist HC system.. so thats the main thing right?

You've got a good point there.  When I was growing up I heard a lot of tales of the evil commies and that our military was doing it's patriotic duty for mom and apple pie.  It wasn't stated explicitly, but the US was defending free enterprise as well.  Sometimes, they'd give an example of Uncle Wilbur and his barber shop.  It was stated that Uncle Wilbur would not be able to open his barber shop across the iron curtain.  None of the mom and pop stores would exist on Main Street.

Today, we face a different fight with a different type of soldier.  The soldier of today is the patient who serves the  American healthcare system.  Some may call it overpriced medicine, but others call it a capitalistic opportunity.  Every patient today enriches the healthcare system and is an example of successful capitalism.  Some may not be able to afford the health care system and die.  These patients are like brave soldiers who give their lives in support of our capitalist healthcare system.

America may be the last example of such a pure capitalist system.  The mom and pop stores have closed due to Wal Mart.  We have to save what is left. This system will be defended to the last red drop of every American patient's blood.  We have the finest healthcare system in the world for investors and we should all be proud. 

Please face the flag and join me in reciting the Pledge of Allegiance.  The Eagle has Landed!

Nicely said - had me laughing there at the end.

DavidAnnArbor

  • Handlebar Stache
  • *****
  • Posts: 1954
  • Age: 53
  • Location: Ann Arbor, Michigan
Re: What comes after the ACA?
« Reply #5256 on: January 03, 2019, 04:14:31 PM »

I understand your frustration, but it's best not to think of insurers as people, you just need to embrace the clinical detachment when interacting with them. By all means be nice to their reps, but to the machine you're just a number spitting out a bunch of claim codes at semi-random intervals. They couldn't care less whether someone touched your pussy or your big toe, it's all codes and procedures to them. They've seen it all.

I appreciate the understanding.  I'm most frustrated by the fact that I would have to seek preapproval for such a routine procedure.  If I were on the pill and wanted to switch to a different one or stop taking it altogether, I can't imagine I'd need "preapproval" for that.

In a week or so, I'll probably be able to laugh at the absurdity of it all and approach it with the clinical detachment that helps keep this insanity in the proper perspective.  But there are just no good encounters to be had with a health insurance company.  Ever.  It's all frustration. 

I don't necessarily know what the better way is, but there has got to be a better way.

You have every right to be angry and fed up with the system. That they would seek preapproval for that is like a needless invasion of personal control, privacy and dignity.

freya

  • Stubble
  • **
  • Posts: 247
Re: What comes after the ACA?
« Reply #5257 on: January 03, 2019, 05:10:05 PM »
Access to preventative care will likely end up reducing overall health care costs...

If you want to get really, really upset about our health care system, and understand why the above statement is almost certainly not true, check out the book "Doctoring Data" or read the author's blog:

https://drmalcolmkendrick.org/

The current article is very interesting.  It points up a fundamental fallacy that has been exploited to the utmost:  1) you can use statistics to prove just about anything, 2) if you show a correlation between Risk Factor A and Disease B, it does not necessarily mean that modifying Risk Factor A will reduce the risk of Disease B. This has a lot to do with the fact that the people/companies who stand to benefit financially are often the ones who sponsor the studies that are used to make blanket primary prevention recommendations.

I guess the CDC must be wrong, then.

https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/PreventiveHealth.html

Quote
Chronic diseases, such as heart disease, cancer, and diabetes, are responsible for 7 of every 10 deaths among Americans each year and account for 75% of the nationís health spending. These chronic diseases can be largely preventable through close partnership with your healthcare team, or can be detected through appropriate screenings, when treatment works best.

Heart disease, cancer, and diabetes may well be present in 70% of people at the end of life, and they also may indeed account for 75% of spending.  It's the assertion that cancer, heart disease, and diabetes are "largely preventable" that's in question.  In fact, that statement is simply absurd.  Here's another statistic for you:  the risk of death for each and every person currently alive is 100%.  No amount of prevention in the world will change that.

Aelias:  My sympathies for your battle with the insurance company over the most outrageous "preapproval" story I've ever heard.  So sorry you had to deal with that.  If you are so inclined, your local consumer watchdog news outlet may be interested in your story, and that may be the best way to shame the insurance company into doing the right thing.

JLee

  • Walrus Stache
  • *******
  • Posts: 5397
Re: What comes after the ACA?
« Reply #5258 on: January 03, 2019, 06:37:49 PM »
Heart disease, cancer, and diabetes may well be present in 70% of people at the end of life, and they also may indeed account for 75% of spending.  It's the assertion that cancer, heart disease, and diabetes are "largely preventable" that's in question.  In fact, that statement is simply absurd.  Here's another statistic for you:  the risk of death for each and every person currently alive is 100%.  No amount of prevention in the world will change that.

We're all gonna die so why bother being healthy? Is that really your argument?

seattlecyclone

  • Magnum Stache
  • ******
  • Posts: 4730
  • Age: 34
  • Location: Seattle, WA
Re: What comes after the ACA?
« Reply #5259 on: January 03, 2019, 07:28:02 PM »
Heart disease, cancer, and diabetes may well be present in 70% of people at the end of life, and they also may indeed account for 75% of spending.  It's the assertion that cancer, heart disease, and diabetes are "largely preventable" that's in question.  In fact, that statement is simply absurd.  Here's another statistic for you:  the risk of death for each and every person currently alive is 100%.  No amount of prevention in the world will change that.

We're all gonna die so why bother being healthy? Is that really your argument?

Being healthy is great in and of itself. The idea that healthy people will use less medical care over their lifetimes, or that regular preventive care actually reduces overall costs in the long run is less clear. Let's call Person A someone who eats an unhealthy diet, never goes to the doctor unless really sick, and dies of a heart attack at age 60. Compare them to Person B whose physician notices risk factors for heart disease at a regular physical examination, gets them on a medication to control blood pressure and cholesterol, and as a result they never develop heart disease and eventually die in their 80s after a few years battling cancer.

I'd rather be Person B than Person A. Most of us probably would. That said, I'd be willing to bet Person B ended up costing more to care for over their lifetime than Person A did. From a pure dollars and cents perspective, the ideal outcome is for someone to die from a sudden illness or injury shortly after they leave the workforce and stop paying into the system. The expensive folks are the ones who enjoy a long retirement with the occasional less-expensive health incident, and an eventual protracted, expensive, deadly illness.
« Last Edit: January 03, 2019, 07:52:54 PM by seattlecyclone »

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5260 on: January 03, 2019, 08:53:33 PM »
I'd be willing to bet Person B ended up costing more to care for over their lifetime than Person A did.

Once upon a time, people made the exact same argument about smokers.  Everyone agreed that they died sooner, but since that meant fewer years of care and a known fixed cost, they were supposed to be cheaper to insure than nonsmokers.  I think that argument lasted less than three years, and now nonsmokers pay lower rates than smokers.  These days, no one argues that smokers use less healthcare.

So if we can accept that being healthier by being a nonsmoker is cheaper to insure, then it's probably not a big step to conclude that being healthier by eating a healthy diet is probably also cheaper to insure.

Improving your diet also has cascading positive effects on your risk of developing heart disease, cancer, and diabetes.  Just like quitting smoking does!  It's really the single best thing you can do for your body, for most people. 

The next time you crave a greasy cheeseburger, remind yourself that smokers crave their coffin nails too and yet we collectively accept that they should know better, and should quit.  Unfortunately, just knowing something is bad for you doesn't help you avoid it.  You also have to want to be healthier, and willing to endure some suffering to get there.

2019 is a new year, friends.  Try to eat less crap.  Future you will thank you.

maizeman

  • Magnum Stache
  • ******
  • Posts: 3575
Re: What comes after the ACA?
« Reply #5261 on: January 03, 2019, 09:14:32 PM »
I'd be willing to bet Person B ended up costing more to care for over their lifetime than Person A did.

Once upon a time, people made the exact same argument about smokers.  Everyone agreed that they died sooner, but since that meant fewer years of care and a known fixed cost, they were supposed to be cheaper to insure than nonsmokers.  I think that argument lasted less than three years, and now nonsmokers pay lower rates than smokers.  These days, no one argues that smokers use less healthcare.

So if we can accept that being healthier by being a nonsmoker is cheaper to insure, then it's probably not a big step to conclude that being healthier by eating a healthy diet is probably also cheaper to insure.

While as far as I know the studies showing lower lifetime healthcare expenditures for smokers continue to be valid, sol, I've never seen anyone make the argument in your bolded statement

Smokers are more expensive to insure because they use more healthcare per year. Once a person is dead they're not using healthcare but they are also not paying health insurance premiums anymore. So lower lifetime healthcare spending resulting from fewer years of life doesn't mean a group should be any cheaper to insure while they are still alive.

A further complication is that in the united states if you die earlier, most of the money you're saving is would have come from medicare, not private insurance. Since you essentially prepay into medicare your entire working life through payroll taxes, dying before you have had a chance to receive significant medicare benefits back ends up being quite good for the government balance sheet. Yet another reason that smokers requiring less total spending in healthcare over their lifetime does not mean that their pre-medicare health insurance premiums would be lower.

seattlecyclone

  • Magnum Stache
  • ******
  • Posts: 4730
  • Age: 34
  • Location: Seattle, WA
Re: What comes after the ACA?
« Reply #5262 on: January 03, 2019, 09:22:53 PM »
Right, given differing lifetimes there's no reason to expect that the person who's cheaper to insure on an annual basis will also be cheaper to insure on a lifetime basis.

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5263 on: January 03, 2019, 10:05:30 PM »
Wow, you guys are brutally cynical. 

Are we really back to hoping everyone dies young so that we have to provide less medical care to old sick people?  What kind of twisted world is that?

I think this may be one of those cases where economics is the wrong metric.  Instead of maximizing the efficiency of our healthcare dollars by murdering everyone when they turn 30, perhaps we we need to adopt a different way of measuring what's best for society.  I'm going to go read up on Bhutan's Gross Domestic Happiness index.

seattlecyclone

  • Magnum Stache
  • ******
  • Posts: 4730
  • Age: 34
  • Location: Seattle, WA
Re: What comes after the ACA?
« Reply #5264 on: January 03, 2019, 10:35:40 PM »
Nope, not hoping everyone dies young, merely pointing out that a world where people live longer may also be a world where we put more of our resources toward medical care. A longer-lived population seems like a desirable thing overall, but it does need to be planned for.

DreamFIRE

  • Handlebar Stache
  • *****
  • Posts: 1596
Re: What comes after the ACA?
« Reply #5265 on: January 03, 2019, 10:38:55 PM »
With sufficient preventive medicine, the smoker or obese person may live to be much older, save all those healthcare dollars that would have been spent on heart disease, and be more likely to suffer from the more expensive Alzheimer's disease.  This was discussed a while back in another thread, but I couldn't quickly locate it.

Paul der Krake

  • Magnum Stache
  • ******
  • Posts: 4454
  • Age: 11
  • Location: USA
Re: What comes after the ACA?
« Reply #5266 on: January 03, 2019, 10:45:23 PM »
30 is the wrong age. You havenít made a dent in all the money it took to get you to graduate high school, or gasp, college.

What we need is a secret drug, concocted by our best scientists. The drug promises the experience of a lifetime, absolute pure bliss, a perfect high that encapsulates everything humans cherish, both consciously and unconsciously. But their is a price to pay: it kills with a formidable efficacy. Only one in a thousand survives to tell others how unvelievably wonderful that experience is, while the other 999 peacefully drift to their deaths, riding the only true high they will ever know.

The government only offers the opportunity to take that drug upon reaching retirement age. Around the country, millions have the conversation with their family. What will they do when their time comes?

JLee

  • Walrus Stache
  • *******
  • Posts: 5397
Re: What comes after the ACA?
« Reply #5267 on: January 03, 2019, 11:48:26 PM »
Nope, not hoping everyone dies young, merely pointing out that a world where people live longer may also be a world where we put more of our resources toward medical care. A longer-lived population seems like a desirable thing overall, but it does need to be planned for.

It's funny you say that, because I can give you a whole list of countries where people both live longer and pay dramatically less for medical care.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 5989
  • Age: 57
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: What comes after the ACA?
« Reply #5268 on: January 04, 2019, 12:05:51 AM »
Person A dies at 60?.. Geez I'm 57, you bet your life I want to be Person B.. Assuming I can afford to live that long in the USA..:)

maizeman

  • Magnum Stache
  • ******
  • Posts: 3575
Re: What comes after the ACA?
« Reply #5269 on: January 04, 2019, 07:37:34 AM »
Wow, you guys are brutally cynical. 

Are we really back to hoping everyone dies young so that we have to provide less medical care to old sick people?  What kind of twisted world is that?

Nope. I'm quite capable of holding the knowledge the smokers really will use less healthcare over their lifetimes and therefore make it easier for medicare to meet its financial obligations in my head while AT THE SAME TIME still wanting fewer (ideally zero) people to smoke.

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5270 on: January 04, 2019, 08:01:29 AM »
Nope. I'm quite capable of holding the knowledge the smokers really will use less healthcare over their lifetimes and therefore make it easier for medicare to meet its financial obligations in my head while AT THE SAME TIME still wanting fewer (ideally zero) people to smoke.

Right, that was the point I was trying to make.  This seems to be a case where we want to sabotage medicare, to spend inefficiently on healthcare, where we desire and actively work towards rising health care costs, and thus rising health insurance prices.  In a thread that has become a discussion about how to lower health insurance prices.

I wasn't seriously suggesting murdering everyone at age 30.  I thought that was clear.

maizeman

  • Magnum Stache
  • ******
  • Posts: 3575
Re: What comes after the ACA?
« Reply #5271 on: January 04, 2019, 08:33:57 AM »
What a productive discussion.

Sol Reply #5260: $A is true.
Maizemain Reply #5261: No $A is false.
Sol Reply #5263: WTF is the matter with you guys, you want to kill children?
Maizeman Reply #5269: No I don't. But $A is still false.
Sol Reply #5270: I wasn't serious guys.

EnjoyIt

  • Handlebar Stache
  • *****
  • Posts: 1399
Re: What comes after the ACA?
« Reply #5272 on: January 04, 2019, 01:21:48 PM »

- CUT -

But at least we don't have a socialist HC system.. so thats the main thing right?

You've got a good point there.  When I was growing up I heard a lot of tales of the evil commies and that our military was doing it's patriotic duty for mom and apple pie.  It wasn't stated explicitly, but the US was defending free enterprise as well.  Sometimes, they'd give an example of Uncle Wilbur and his barber shop.  It was stated that Uncle Wilbur would not be able to open his barber shop across the iron curtain.  None of the mom and pop stores would exist on Main Street.

Today, we face a different fight with a different type of soldier.  The soldier of today is the patient who serves the  American healthcare system.  Some may call it overpriced medicine, but others call it a capitalistic opportunity.  Every patient today enriches the healthcare system and is an example of successful capitalism.  Some may not be able to afford the health care system and die.  These patients are like brave soldiers who give their lives in support of our capitalist healthcare system.

America may be the last example of such a pure capitalist system.  The mom and pop stores have closed due to Wal Mart.  We have to save what is left. This system will be defended to the last red drop of every American patient's blood.  We have the finest healthcare system in the world for investors and we should all be proud. 

Please face the flag and join me in reciting the Pledge of Allegiance.  The Eagle has Landed!

Our healthcare system is far from capitalist.  At first glance it looks like it is, but the government is so entrenched into the system that we lose most of the positives capitalism has to offer.  This is one of the big reasons why our system is so expensive.  Corruption and regulation that helps certain entities win while the average American suffers.  Government is picking winners and losers and the government has chosen that the losers will be the American people.  This is not Capitalism. 

ysette9

  • Magnum Stache
  • ******
  • Posts: 4413
  • Location: Bay Area, CA
    • Insert Snappy Title Here (Journal)
Re: What comes after the ACA?
« Reply #5273 on: January 04, 2019, 01:32:09 PM »

- CUT -

But at least we don't have a socialist HC system.. so thats the main thing right?

You've got a good point there.  When I was growing up I heard a lot of tales of the evil commies and that our military was doing it's patriotic duty for mom and apple pie.  It wasn't stated explicitly, but the US was defending free enterprise as well.  Sometimes, they'd give an example of Uncle Wilbur and his barber shop.  It was stated that Uncle Wilbur would not be able to open his barber shop across the iron curtain.  None of the mom and pop stores would exist on Main Street.

Today, we face a different fight with a different type of soldier.  The soldier of today is the patient who serves the  American healthcare system.  Some may call it overpriced medicine, but others call it a capitalistic opportunity.  Every patient today enriches the healthcare system and is an example of successful capitalism.  Some may not be able to afford the health care system and die.  These patients are like brave soldiers who give their lives in support of our capitalist healthcare system.

America may be the last example of such a pure capitalist system.  The mom and pop stores have closed due to Wal Mart.  We have to save what is left. This system will be defended to the last red drop of every American patient's blood.  We have the finest healthcare system in the world for investors and we should all be proud. 

Please face the flag and join me in reciting the Pledge of Allegiance.  The Eagle has Landed!

Our healthcare system is far from capitalist.  At first glance it looks like it is, but the government is so entrenched into the system that we lose most of the positives capitalism has to offer.  This is one of the big reasons why our system is so expensive.  Corruption and regulation that helps certain entities win while the average American suffers.  Government is picking winners and losers and the government has chosen that the losers will be the American people.  This is not Capitalism.
At first blush your argument makes sense. However I feel that it breaks down when you look outside of the US. Every other developed nation has a more regulated healthcare system and also enjoys, on average, better outcomes than us for around half the cost we spend, give or take a few percentage points. The data just don’t seem to back you up.

EnjoyIt

  • Handlebar Stache
  • *****
  • Posts: 1399
Re: What comes after the ACA?
« Reply #5274 on: January 04, 2019, 05:21:57 PM »

- CUT -

But at least we don't have a socialist HC system.. so thats the main thing right?

You've got a good point there.  When I was growing up I heard a lot of tales of the evil commies and that our military was doing it's patriotic duty for mom and apple pie.  It wasn't stated explicitly, but the US was defending free enterprise as well.  Sometimes, they'd give an example of Uncle Wilbur and his barber shop.  It was stated that Uncle Wilbur would not be able to open his barber shop across the iron curtain.  None of the mom and pop stores would exist on Main Street.

Today, we face a different fight with a different type of soldier.  The soldier of today is the patient who serves the  American healthcare system.  Some may call it overpriced medicine, but others call it a capitalistic opportunity.  Every patient today enriches the healthcare system and is an example of successful capitalism.  Some may not be able to afford the health care system and die.  These patients are like brave soldiers who give their lives in support of our capitalist healthcare system.

America may be the last example of such a pure capitalist system.  The mom and pop stores have closed due to Wal Mart.  We have to save what is left. This system will be defended to the last red drop of every American patient's blood.  We have the finest healthcare system in the world for investors and we should all be proud. 

Please face the flag and join me in reciting the Pledge of Allegiance.  The Eagle has Landed!

Our healthcare system is far from capitalist.  At first glance it looks like it is, but the government is so entrenched into the system that we lose most of the positives capitalism has to offer.  This is one of the big reasons why our system is so expensive.  Corruption and regulation that helps certain entities win while the average American suffers.  Government is picking winners and losers and the government has chosen that the losers will be the American people.  This is not Capitalism.
At first blush your argument makes sense. However I feel that it breaks down when you look outside of the US. Every other developed nation has a more regulated healthcare system and also enjoys, on average, better outcomes than us for around half the cost we spend, give or take a few percentage points. The data just donít seem to back you up.

I'm not saying the US healthcare system is better or worse than anywhere else.  If you ask me, I think our system is completely fucked up. 

My comment is that our healthcare system is not capitalist.

seattlecyclone

  • Magnum Stache
  • ******
  • Posts: 4730
  • Age: 34
  • Location: Seattle, WA
Re: What comes after the ACA?
« Reply #5275 on: January 04, 2019, 05:34:43 PM »
How do you judge whether one health care system is "more regulated" than another? Collect all the regulations in a PDF and count the pages? Count the number of hospital staff whose job is to ensure compliance with regulations? Something else? I'm not so sure that other countries are more regulated, but they are definitely regulated differently. The regulations elsewhere seem to place a higher priority on universal access to care. Our regulations are likely comparable in volume, they just focus on different things.

Monkey Uncle

  • Handlebar Stache
  • *****
  • Posts: 1468
  • Location: West-by-god-Virginia
Re: What comes after the ACA?
« Reply #5276 on: January 04, 2019, 05:44:09 PM »
How do you judge whether one health care system is "more regulated" than another? Collect all the regulations in a PDF and count the pages? Count the number of hospital staff whose job is to ensure compliance with regulations? Something else? I'm not so sure that other countries are more regulated, but they are definitely regulated differently. The regulations elsewhere seem to place a higher priority on universal access to care. Our regulations are likely comparable in volume, they just focus on different things.

Yep, our regulations focus on making hospital and health insurance executives rich.

EnjoyIt

  • Handlebar Stache
  • *****
  • Posts: 1399
Re: What comes after the ACA?
« Reply #5277 on: January 04, 2019, 06:34:42 PM »
How do you judge whether one health care system is "more regulated" than another? Collect all the regulations in a PDF and count the pages? Count the number of hospital staff whose job is to ensure compliance with regulations? Something else? I'm not so sure that other countries are more regulated, but they are definitely regulated differently. The regulations elsewhere seem to place a higher priority on universal access to care. Our regulations are likely comparable in volume, they just focus on different things.

The word regulations is like a dirty word.  But I'm sure everyone will agree that some regulations are necessary while others may not be.  Currently there is a lot of waste in between the physician and the care the patient receives.  All of it costs a lot of money and someone has to pay for it.  In the end it is the consumer who pays either through higher premiums and deductibles or through direct pay to the pharmaceuticals, hospitals and providers. 

Small example: The government (CMS) has dictated that to be able to bill fully for a particular exam and treatment you must hit certain documentation criteria.  If you do not meet said criteria you either get no reimbursement or a tiny fraction of it.  To help meet this criteria physicians are hiring scribes to follow them around and help document for them.  Now, large scribe corporations exist to help meet that demand and are asking anywhere from $25-$30 per hour to provide a trained scribe just to jot down the physicians notes.  Who do you think ends up paying for the scribes?  There are tons of such regulations that add zero value to the patient but cost the system money. 

pecunia

  • Pencil Stache
  • ****
  • Posts: 946
Re: What comes after the ACA?
« Reply #5278 on: January 05, 2019, 12:20:51 PM »
-  Big SNIIIIP! -
I'm not saying the US healthcare system is better or worse than anywhere else.  If you ask me, I think our system is completely fucked up. 

My comment is that our healthcare system is not capitalist.

Then what is it?  It's not Socialist, but part of it is.  Some of medicare is Socialist.  Let's look at what Wikipedia says capitalism is:

Capitalism is an economic system based on the private ownership of the means of production and their operation for profit.[1][2][3] Characteristics central to capitalism include private property, capital accumulation, wage labor, voluntary exchange, a price system, and competitive markets.[4][5] In a capitalist market economy, decision-making and investment are determined by every owner of wealth, property or production ability in financial and capital markets, whereas prices and the distribution of goods and services are mainly determined by competition in goods and services markets.[6][7]

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

Private Property - check
capital accumulation - triple check
wage labor - check  (I hear stories of them giving nurses a raw deal.)
voluntary exchange - Beep Not Really (It's them or die)
a price system - They tell you what it costs and you pay if'n you got the money
competitive markets - I'd have to say no.  Sure you got the choice of them or some Mexican doctor in a back alley, but that's not a fair choice

Decision making and pricing are determined by every owner of wealth - Seems that way.  They ask and you pay.

Seems to fail greatly on the competition part.

I question whether this capitalist system thing should even be applied to health care.  I mean, it's not as if you really have much choice in many medical matters.  It's like the round peg in the square hole.

Yeh - It's completely "fouled" up.

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5279 on: January 05, 2019, 12:43:16 PM »
Sure you got the choice of them or some Mexican doctor in a back alley, but that's not a fair choice

Medical tourism is definitely a thing.  My FIL gets all of his dental work done in Mexico.  There was a time when Canada was doing a booming business in laser eye surgery for Americans.  You can fly to eastern Europe and have a week's vacation, get a boob job done, and fly home for less than the cost of the same surgery in the states.

Other countries can and do have superior medical care compared to the US, especially for routine stuff.  If you have a rare cancer and want experimental treatment, the US healthcare system is the place to be.   If you just want a nose job or root canal, you're going to overpay in America.

EnjoyIt

  • Handlebar Stache
  • *****
  • Posts: 1399
Re: What comes after the ACA?
« Reply #5280 on: January 05, 2019, 03:41:46 PM »
Sure you got the choice of them or some Mexican doctor in a back alley, but that's not a fair choice

Medical tourism is definitely a thing.  My FIL gets all of his dental work done in Mexico.  There was a time when Canada was doing a booming business in laser eye surgery for Americans.  You can fly to eastern Europe and have a week's vacation, get a boob job done, and fly home for less than the cost of the same surgery in the states.

Other countries can and do have superior medical care compared to the US, especially for routine stuff.  If you have a rare cancer and want experimental treatment, the US healthcare system is the place to be.   If you just want a nose job or root canal, you're going to overpay in America.

And people fly to the US for medical care as well.  Medical Tourism goes both ways. I see patients all the time with serious complications of getting surgery in Mexico.  I am biased though because I only see the bad outcomes and never the good outcomes.  The get ones stay home.

Also, most countries that have socialist healthcare have a portion of it intermingled with capitalism.  In the US we have some capitalism in our healthcare.  A good example is Lasik Eye surgery.  It is easy to have competition and transparent pricing in a 100% elective procedures that insurance does not cover.  At one time it used to cost thousands to get both eyes done.  Now you can have the procedure for a few hundred.  Capitalism at its finest.  Emergency care does not fit that model but Emergency care is a tiny percentage of healthcare expenditures in the US.  Most of healthcare is elective or semi elective.  Even things like broken bones, Cholecystectomies (gall bladder surgeries,) stress tests, etc.  Many of them can are not done immediately and can wait a few hours, days (or even weeks depending on the medical care required) to look for a good doctor at the right price if that information is available.  The information is not available making it very difficult to allow capitalist market forces take affect. 

Don't get me wrong, I am not for a 100% Capitalist system.  We need a safety net for those that can't afford healthcare.  But some real capitalism would help cut some of these exorbitant fees and that can never happen without 100% price transparency.

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5281 on: January 05, 2019, 04:02:25 PM »
But some real capitalism would help cut some of these exorbitant fees and that can never happen without 100% price transparency.

So would a lot less capitalism.

EnjoyIt

  • Handlebar Stache
  • *****
  • Posts: 1399
Re: What comes after the ACA?
« Reply #5282 on: January 05, 2019, 04:11:40 PM »
But some real capitalism would help cut some of these exorbitant fees and that can never happen without 100% price transparency.

So would a lot less capitalism.

I really believe that a pure socialist healthcare system in the US would not work because of how entrenched the insurance and pharmaceutical industry is with politics.  But, having a social backbone for all interlaced with pure capitalism for those who want it would be ideal.  Just about every socialist healthcare system in the world has some capitalism interlaced in it.  Some countries have government paid healthcare that is processed for by private insurance.  Other countries have private insurance for a higher level of care.

Today, if everyone in the US was instantly switched over to Medicare and everyone was taxed instead of 2.9% for medicare they are taxed 10-15% very little would change because the cost of delivering care will still stay exorbitantly high.  Single payer is not the panacea of fixing the real problem of cost.  Keep in mind that one of the reasons cost is so high in the US is because of government intervention. The government has decided that certain business entities will succeed on the backs of the middle class and the rich while the poor make do with what is given to them.  Medicare for all will change very little.

AnswerIs42

  • Stubble
  • **
  • Posts: 153
Re: What comes after the ACA?
« Reply #5283 on: January 05, 2019, 06:36:40 PM »
I really believe that a pure socialist healthcare system in the US would not work because of how entrenched the insurance and pharmaceutical industry is with politics.  But, having a social backbone for all interlaced with pure capitalism for those who want it would be ideal.  Just about every socialist healthcare system in the world has some capitalism interlaced in it.  Some countries have government paid healthcare that is processed for by private insurance.  Other countries have private insurance for a higher level of care.

Works quite well in the UK, it's amazing how much cheaper private health insurance / treatment becomes when the providers have to compete with free...

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5284 on: January 05, 2019, 06:56:29 PM »
I really believe that a pure socialist healthcare system in the US would not work

No one is suggesting that, to my knowledge. 

But having a more socialist system than we currently have would clearly be step in the right direction, in my opinion.  Having profit-driven corporations as the only means of providing medical care to the population seems like a bad solution, not so different from the days of private fire departments.  There will always be a capitalist incentive for some folks to buy private health insurance and private health care, but I think our system is handicapped by that being the only option.  I think we need baseline coverage for everyone, provided collectively to support our general welfare. 

Like in the UK, that baseline coverage will come with restrictions.  There will be limited options, and long waits, and medical review boards.  But at least it will be better than the current system, in which law abiding middle class folks get to pay through the nose to support all of the freeloaders and costs continue to spiral out of control.

pecunia

  • Pencil Stache
  • ****
  • Posts: 946
Re: What comes after the ACA?
« Reply #5285 on: January 05, 2019, 10:26:33 PM »

- SNIP -

I really believe that a pure socialist healthcare system in the US would not work because of how entrenched the insurance and pharmaceutical industry is with politics.  But, having a social backbone for all interlaced with pure capitalism for those who want it would be ideal.  Just about every socialist healthcare system in the world has some capitalism interlaced in it.  Some countries have government paid healthcare that is processed for by private insurance.  Other countries have private insurance for a higher level of care.

Today, if everyone in the US was instantly switched over to Medicare and everyone was taxed instead of 2.9% for medicare they are taxed 10-15% very little would change because the cost of delivering care will still stay exorbitantly high.  Single payer is not the panacea of fixing the real problem of cost.  Keep in mind that one of the reasons cost is so high in the US is because of government intervention. The government has decided that certain business entities will succeed on the backs of the middle class and the rich while the poor make do with what is given to them.  Medicare for all will change very little.

The last I heard was that the government is, well, is the people.  The government is to be set up to serve the people.  Or, at least it is supposed to be.  I think if enough people get riled about being ripped off when they get their medical care, the government will almost magically change.  The government is an organization that will respond to the feedback given by the people.  It is certain that the "business entities" will provide a lag and dampening mechanism.  Modified health care will be criteria for the politicians which the people will vote for.  It is happening already.  The stodgy medical industry may be dragged into the change kicking and screaming, but it will happen.

In the past, efforts to make such changes have been thwarted by industry propaganda.  I don't think it will be effective this time.  Fool me once shame on you, fool me too many times, not this time.  The facts are now readily available to anyone with a computer and this is an issue that affects almost everyone's life.

The cusp point in American health care is approaching.

I think just paying the tax would make things a whole lot simpler.

Naturally - opinions will differ.

Roadrunner53

  • Handlebar Stache
  • *****
  • Posts: 2168
Re: What comes after the ACA?
« Reply #5286 on: January 06, 2019, 06:53:38 AM »
Since the government is partially shut down are ACA subsidies still being paid?

EnjoyIt

  • Handlebar Stache
  • *****
  • Posts: 1399
Re: What comes after the ACA?
« Reply #5287 on: January 06, 2019, 09:04:29 AM »

- SNIP -

The last I heard was that the government is, well, is the people.  The government is to be set up to serve the people.  Or, at least it is supposed to be.  I think if enough people get riled about being ripped off when they get their medical care, the government will almost magically change.  The government is an organization that will respond to the feedback given by the people.  It is certain that the "business entities" will provide a lag and dampening mechanism.  Modified health care will be criteria for the politicians which the people will vote for.  It is happening already.  The stodgy medical industry may be dragged into the change kicking and screaming, but it will happen.

The cusp point in American health care is approaching.

-snip-

Idealistically correct. Eventually if the people want something they will get it. And there are plenty of pissed off people out there today though I think they are confused on what they want. People confuse healthcare with health insurance and believe more affordable insurance is the answer. It took over a year for people on this thread to start to realize the problem isnít really health insurance but the cost of healthcare delivery. Until the people see that as the real problem all they will demand is insurance.

Although less expensive, Medicare with all its addons isnít really cheap. Sure it is more affordable than blue cross or Aetna but just switching the population over to Medicare is not the solution on its own. We need a much more comprehensive fix that cuts the cost of healthcare delivery. Just think about it, cutting waste by 10% would be enough money to cover every American that is outside the current ACA laws. Cutting 10% is not that hard though it would require firing a whole lot of Americans that provide bureaucratic instead of patient centric services.

As I stated before, I donít think we are there yet and I think it will need to get worse before it gets better.

« Last Edit: January 06, 2019, 10:33:51 AM by EnjoyIt »

Roland of Gilead

  • Handlebar Stache
  • *****
  • Posts: 1688
Re: What comes after the ACA?
« Reply #5288 on: January 06, 2019, 09:08:54 AM »
Since the government is partially shut down are ACA subsidies still being paid?

Seem to be.  IRS is still collecting taxes too.

ysette9

  • Magnum Stache
  • ******
  • Posts: 4413
  • Location: Bay Area, CA
    • Insert Snappy Title Here (Journal)
Re: What comes after the ACA?
« Reply #5289 on: January 06, 2019, 01:56:08 PM »
I feel like a big cost saver in all other developed countries is taking advantage of the single-payer status to demand lower prices from healthcare providers. That is something we fail spectacularly at doing overall in the US.

DreamFIRE

  • Handlebar Stache
  • *****
  • Posts: 1596
Re: What comes after the ACA?
« Reply #5290 on: January 06, 2019, 04:07:42 PM »
I feel like a big cost saver in all other developed countries is taking advantage of the single-payer status to demand lower prices from healthcare providers. That is something we fail spectacularly at doing overall in the US.

Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5291 on: January 06, 2019, 04:18:54 PM »
Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

No.  They do not "underpay" they pay less than private insurance pays.  Other countries provide superior care at a price lower than medicare and medicaid pay, by controlling what practitioners can take as profit and by rationing what services can be provided based on actual evidence of efficacy, instead of patient demands.

You can stop repeating this false claim about medicare/medicaid "underpayment".  It is totally possible to provide better care at a lower cost than even these programs pay.  Every other developed country in the world is already doing it.

pecunia

  • Pencil Stache
  • ****
  • Posts: 946
Re: What comes after the ACA?
« Reply #5292 on: January 06, 2019, 04:23:23 PM »
I feel like a big cost saver in all other developed countries is taking advantage of the single-payer status to demand lower prices from healthcare providers. That is something we fail spectacularly at doing overall in the US.

Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

Where have they gone?  It seems quite rare to have a hospital having a going out of business sale.  Are a lot of doctors and nurses retiring early?  Do they leave to perform another vocation?

DavidAnnArbor

  • Handlebar Stache
  • *****
  • Posts: 1954
  • Age: 53
  • Location: Ann Arbor, Michigan
Re: What comes after the ACA?
« Reply #5293 on: January 06, 2019, 05:43:53 PM »
I feel like a big cost saver in all other developed countries is taking advantage of the single-payer status to demand lower prices from healthcare providers. That is something we fail spectacularly at doing overall in the US.

Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

Medicaid payments are the one thing that are saving rural hospitals from going under now that the Affordable Care Act increased Medicaid reimbursement rates. In states like Kentucky and West Virginia the ACA's Medicaid expansion means many more residents are now covered by Medicaid than prior to the Act.
Medicaid expansion in West Virginia has provided a boon to health service providers, and there are by far more health care workers in that state than there are coal miners. Moreover, health care employment in West Virginia is a growing field.


DreamFIRE

  • Handlebar Stache
  • *****
  • Posts: 1596
Re: What comes after the ACA?
« Reply #5294 on: January 06, 2019, 06:25:23 PM »
Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

No.  They do not "underpay" they pay less than private insurance pays

Sol, you have no clue what you talking about.  I have been in the field for years.  They most definitely do not pay enough to healthcare providers for the cost of the healthcare services provided.  I know of healthcare providers that have had higher volume but were actually taking a loss because too much of the volume was either Medicare or Medicaid.

Again, don't add your two cents by making up stuff as usual when you don't know the facts.

DreamFIRE

  • Handlebar Stache
  • *****
  • Posts: 1596
Re: What comes after the ACA?
« Reply #5295 on: January 06, 2019, 06:28:05 PM »
I feel like a big cost saver in all other developed countries is taking advantage of the single-payer status to demand lower prices from healthcare providers. That is something we fail spectacularly at doing overall in the US.

Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

Where have they gone?  It seems quite rare to have a hospital having a going out of business sale.  Are a lot of doctors and nurses retiring early?  Do they leave to perform another vocation?

It's not rare at all for healthcare facilities to go out of business.  Do some searching - I actually posted a link to an article about it earlier in this thread.  It's not new news.  This was occurring even before the ACA.

sol

  • Walrus Stache
  • *******
  • Posts: 8369
  • Age: 42
  • Location: Pacific Northwest
Re: What comes after the ACA?
« Reply #5296 on: January 06, 2019, 06:43:16 PM »
I have been in the field for years. 

Ah, so you're one of those overpaid people who have created this problem!  It all makes sense now.

Here's a fact for you: medical providers in most other developed countries make less money than the same people in the US, and provide care that is equal or better.  In the United States, we pay our average medical practitioners too much.  Everyone, from brain surgeons to GPs, gets paid more than they are worth in other developed nations.  That's part of the reason why healthcare in the US is so expensive. 

We pay you too much in absolute dollars, and we pay you too much as a percentage of GDP. 

In addition to paying too much in salaries, doctors in the US order more tests, and more expensive tests, than their foreign counterparts.  They not only take more money from patients for themselves, they take more money from patients than is necessary for their care and treatment.

In addition to paying too much for salaries and unnecessary tests and procedures, we pay too much for drugs.  Identical products can be had north or south of the border for a fraction of the cost.

There are logical reasons for all of this.  We've let the AMA and the pharma industry and the insurance and litigation industries drive up prices to increase their own profits, but the fact remains that other countries don't have these problems.  They charge less, and they provide better care, and we could do it too.

Lowering reimbursement rates for medicaid and medicare, as they do in those other countries that provide superior care at lower cost, is probably a good start.  Yes, I understand that this comes with a whole host of associated problems that Americans won't like, but it definitely works everywhere else that has tried it and I have no reason to believe that it wouldn't work here.

You, however, are unlikely to agree because you are personally profiting from the status quo, apparently.  That's fine.  You can continue to accuse me of "making up stuff as usual" despite the salary data backing me up on this point.  You clearly have a personal interest in a particular narrative.  I do not.


Paul der Krake

  • Magnum Stache
  • ******
  • Posts: 4454
  • Age: 11
  • Location: USA
Re: What comes after the ACA?
« Reply #5297 on: January 06, 2019, 06:48:01 PM »
Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

No.  They do not "underpay" they pay less than private insurance pays

Sol, you have no clue what you talking about.  I have been in the field for years.  They most definitely do not pay enough to healthcare providers for the cost of the healthcare services provided.  I know of healthcare providers that have had higher volume but were actually taking a loss because too much of the volume was either Medicare or Medicaid.

Again, don't add your two cents by making up stuff as usual when you don't know the facts.
Taking a loss is the name of the game. There is no incentive to show profitability, ever. There is no incentive to actually bring down costs.

We know that it is in fact possible to deliver healthcare at cheaper cost, because. other. people. do. it. That's the proof. It's been done.

Your claim of "being in the field" is about as convincing as a little league expert saying it's impossible to throw a baseball faster than 70 mph because you've never seen it happen.

DreamFIRE

  • Handlebar Stache
  • *****
  • Posts: 1596
Re: What comes after the ACA?
« Reply #5298 on: January 06, 2019, 06:52:54 PM »
I have been in the field for years. 

Ah, so you're one of those overpaid people who have created this problem!  It all makes sense now.

I'm not a clinical worker, but I've done work for/with hospitals for about 30 years.  I'm actually underpaid compared to you federal workers who also get generous pensions.
https://www.heritage.org/jobs-and-labor/report/why-it-time-reform-compensation-federal-employees

You're comparing other countries that have completely different laws than us.  Whether there could be other changes to deregulated healthcare, take government out of the picture, and reduce costs (as Enjoy It mentioned) is another factor.  That does not refute what I stated about Medicare and Medicaid not paying sufficiently for services rendered.  It's bad enough that some doctors refuse to take those patients.

Again, I'm not personally profiting.  I'm not a clinical worker and could be way ahead as a federal worker, probably enjoying free extra vacation now and a huge pension waiting for me.

DreamFIRE

  • Handlebar Stache
  • *****
  • Posts: 1596
Re: What comes after the ACA?
« Reply #5299 on: January 06, 2019, 06:59:31 PM »
Medicare and Medicaid already underpay healthcare providers significantly, so that's not the type of price control we want to see.  We've lost too many healthcare providers as it is.

No.  They do not "underpay" they pay less than private insurance pays

Sol, you have no clue what you talking about.  I have been in the field for years.  They most definitely do not pay enough to healthcare providers for the cost of the healthcare services provided.  I know of healthcare providers that have had higher volume but were actually taking a loss because too much of the volume was either Medicare or Medicaid.

Again, don't add your two cents by making up stuff as usual when you don't know the facts.
Taking a loss is the name of the game. There is no incentive to show profitability, ever. There is no incentive to actually bring down costs.

That's simply not true.  And sadly, many times bringing down costs actually hurts patient care or means eliminating services causing patients to travel further to get care.