ACA, rising healthcare costs, and shortage of doctors

The longer I spend reading and debating about this, the more convinced I am that, if we want financial sustainability in health care, we have to go all-or-nothing. Either cash-only abolish insurance which would be associated with dropping prices right away. No one likes this because death is unacceptable, and because being on your own causes you to save money, and our government does not want us to save money, they want us to spend it all, and then some. So if we don't take that approach, we need a full government takeover of the industry.

Government is going to continually claw for ways to restrain price increases, but everything is escapable. The 80/20 rule? It encourages rising premiums (because the more you charge-and-spend, the more you keep). The pre-existing condition rule, the 26-year-old children rule? Payouts explode, so shave benefits wherever you can and raise premiums. Not allowed to raise premiums more than 10% a year? Raise them 9.9% a year. People are not allowed to "opt out," but can't afford to opt in? Opt out anyway and forego the tax refund. Finally put in place every last control you can, every last mandate and restriction and cap on insurance companies, and it's financially nonviable? Then what? Victory is ours? No, the company folds and goes out of business. It is completely impossible to chase everyone around and try and force them to behave in contrived economic way, unless you abolish any private aspect about it all becomes the United States Department of Health Care. Private businesses and consumers will all find their way around every regulation until government completely takes them over, sets wages, sets reimbursement rates, the whole nine yards.

There really can be no freedom in this industry if we want all the care we need to be both provided and paid for. We either have government destroy choice and control everything, or we decide to control nothing and let people make their own decisions about saving money for health care or accepting the consequence that they won't get what they won't pay for.

The worst worst worst thing government could do is maximize access and not control costs. PPACA has done exactly that. Maximizes access, fails to control costs. And liberals seem to hint that they understand this, and see it as progress anyway, because if it makes the problem worse fast enough, we'll have to overhaul it even more.

Neomalthusian said:

Yes it is. It ALREADY is an entitlement, because at the moment of need, a person is entitled to care. By virtue of providers' requirement to provide care on the basis of need, we are very literally entitled to life-saving and life-prolonging medical care.

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That doesn't make sense. To some extent, the policy of providing life saving emergency care could be seen as an entitlement maybe. The subsidies that the we provide under the ACA to help low income people afford insurance is an entitlement.

But the public option is not. The public option would charge whatever it's costs are to its customers. They could use subsidies if they are low income just the same as with private insurance companies.

Neomalthusian said:

Your entire post is already too complex, because it's trying to foresee how private insurance companies would interact with a public insurance program that is not subject to the same market forces. The possibilities about how this plays out are endless. Step back from that rat maze for a moment and just think about the cost of medical care, and the amount we spend on it per capita.

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On one hand, you're saying you want to talk about how to control costs, but on the other hand you're saying talking about how to control costs is too complicated for you to want to talk about it. Not really sure what to say about that. If you think debating policy is too complicated, then there isn't really anything we have to talk about.

Neomalthusian said:

The ability of government to control cost growth depends on how trustworthy they are to 1) give both patients and providers some unpopular answers, denying them the care they arguably need, or denying providers the reimbursement of the amount they need to charge, and 2) not be corrupted by big business who will be looking to infiltrate the departments making regulatory decisions.

And this is really the main problem with government health "insurance." Government is averse to giving unpopular answers (political self-sacrifice) and has shown that it frequently welcomes industry insiders into the regulatory agencies that oversee those industries.

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Well, it has worked everywhere else that they've done it. Are you saying that you think the US's government is hopelessly and irreparably more corrupt than the governments of places like Morocco, Cuba, France, Germany, Canada, etc? If so, if our government is uniquely uber corrupted by corporations, which there is some truth to, then we need to tackle that head on regardless of health care. We shouldn't just give up and let the corporations run the show, we should overturn citizens united, put much stricter limits on corporate lobbying, etc.

teamosil said:

That doesn't make sense. To some extent, the policy of providing life saving emergency care could be seen as an entitlement maybe. The subsidies that the we provide under the ACA to help low income people afford insurance is an entitlement.

But the public option is not. The public option would charge whatever it's costs are to its customers.

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Are you sure? Raising taxes is unpopular. Why couldn't it tack it on to the debt?

On one hand, you're saying you want to talk about how to control costs, but on the other hand you're saying talking about how to control costs is too complicated for you to want to talk about it. Not really sure what to say about that.

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No, hang on. What's too complicated is the thought-experiment of speculating how private insurance companies would interact with a government insurance system that is not subject to market forces.

I've read that our outpatient medical care is more than twice as expensive as Sweden's, and Sweden's is the #2 most expensive outpatient medical care in the world. Even with a public option, how does the USG contain that? How will it force those prices down? Health care liberals seem to celebrate the notion that the poor and uninsured can finally stop using the ER and get the outpatient care they've previously been denied... but that care that they can now access is already more than double the price of the runner-up in this category (Sweden). How do we apply the brakes on this?

Are you saying that you think the US's government is hopelessly and irreparably more corrupt than the governments of places like Morocco, Cuba, France, Germany, Canada, etc? If so, if our government is uniquely uber corrupted by corporations, which there is some truth to, then we need to tackle that head on regardless of health care.

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Yes I am saying that, and you don't tackle that head-on by giving it more regulatory power than it had before.

We shouldn't just give up and let the corporations run the show,

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We already have.

Neomalthusian said:

Are you sure? Raising taxes is unpopular. Why couldn't it tack it on to the debt?

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I'm getting the sense you may be unclear on how the public option works. It isn't paid for by either taxes or borrowing. It is a service that you guy. It's customers would be people who chose between a private insurance company and the public insurance company. They would make payments to it for that service just like they do to a private insurance company.

I honestly don't get why the tea party got so outraged about it. If they don't want to us a public option, they could just continue using private insurers. But they didn't want anybody to have that option for some reason... Mostly to do with conspiracy theories I think.

Neomalthusian said:

No, hang on. What's too complicated is the thought-experiment of speculating how private insurance companies would interact with a government insurance system that is not subject to market forces.

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I don't really get where you're coming from with the "too complicated" angle. Life is complicated. If we want to talk about life, it is going to be complicated.

Neomalthusian said:

I've read that our outpatient medical care is more than twice as expensive as Sweden's, and Sweden's is the #2 most expensive outpatient medical care in the world. Even with a public option, how does the USG contain that? How will it force those prices down? Health care liberals seem to celebrate the notion that the poor and uninsured can finally stop using the ER and get the outpatient care they've previously been denied... but that care that they can now access is already more than double the price of the runner-up in this category (Sweden). How do we apply the brakes on this?

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I think I already covered that. The public option could negotiate harder than individual insurance companies and would eliminate the costs of profit taking.

A lot of what is wrong with our health care costs is basically extortion. Health care is fairly inelastic- meaning that people will buy it at any price. If you need a pill to keep you alive, you'll pay anything up to all you have and all you can borrow to get it. The people who make those pills know that. We need a much better, more altruistic, more powerful, entity representing us.

Neomalthusian said:

Yes I am saying that, and you don't tackle that head-on by giving it more regulatory power than it had before.

We already have.

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Maybe you have. I am nowhere near ready to give up on the country. We need to fix it.

teamosil said:

I'm getting the sense you may be unclear on how the public option works. It isn't paid for by either taxes or borrowing. It is a service that you guy. It's customers would be people who chose between a private insurance company and the public insurance company. They would make payments to it for that service just like they do to a private insurance company.

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So the public option is revenue neutral? The expenditures on care cannot exceed the monthly cost to have it? In that case, where is its benefit? I thought the public option is where the sickest, poorest folks would flock, because private companies can't by any stretch of the imagination afford to offer someone who needs $100,000 of health care per year a $250 monthly premium policy. So they look to government. No? Would government make them pay more than they could afford? Where would government get the extra cash to cover the influx of people who can't strike an affordable deal in the private market?

I think I already covered that. The public option could negotiate harder than individual insurance companies and would eliminate the costs of profit taking.

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How do you know? What would give the bureaucracy an incentive to negotiate more than the private companies have? If private companies are competitive with one another, and paying out too much for a service or medicine raises their rates, which raises the likelihood people will drop the policy, that is an incentive to bargain prices down. What is the government's incentive to do so? What forces it to negotiate harder than a private company?

A lot of what is wrong with our health care costs is basically extortion. Health care is fairly inelastic- meaning that people will buy it at any price. If you need a pill to keep you alive, you'll pay anything up to all you have and all you can borrow to get it. The people who make those pills know that. We need a much better, more altruistic, more powerful, entity representing us.

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And you think the government is altruistic? The only rational way to address the artificial inflexibility of demand is to let it become flexible again. That means to only give people what they themselves directly pay for. No one with a $30k/yr income would pay $1,000 a day for a pill, do you know why? Because it's impossible for him to. No one will lend a guy that sort of money either. And so do you know what happens next? The company doesn't make any money on their $1,000/day medication, so it has to find a way to drop prices to levels where people would actually pay for them.

Neomalthusian said:

So the public option is revenue neutral? The expenditures on care cannot exceed the monthly cost to have it?

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Correct.

Neomalthusian said:

In that case, where is its benefit?

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Again, the benefits come from having an entity that isn't trying to extract profit from it's customers that is big enough to push harder on prices in the game.

Neomalthusian said:

How do you know? What would give the bureaucracy an incentive to negotiate more than the private companies have? If private companies are competitive with one another, and paying out too much for a service or medicine raises their rates, which raises the likelihood people will drop the policy, that is an incentive to bargain prices down. What is the government's incentive to do so? What forces it to negotiate harder than a private company?

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Well, first off, if it doesn't manage to push prices down better than the insurance companies do, then no harm would be done. People just wouldn't use the public option if it cost more.

But, again, in every country in the world that has adopted it, the public option or single payer has managed to negotiate prices down much more effectively than the private insurance companies have. For example, if some company makes a new medication and they want to sell it for $150 a pill, and they sell it to all the insurance companies at the same price, then it doesn't hurt them to carry it. They just jack up their prices enough to cover it and add on a nice fat markup and all the other companies do the same, so they aren't giving up any competitive advantage. Heck, the more expensive it is, the more room there is for markup. They can screw us over like crazy and it doesn't matter. We still need what they have. Everybody hates the insurance companies, but that has no effect on them.

Companies can't do that in a normal industry where the consumers are picking the products to buy and are well informed, but like I discussed earlier, that isn't the case in health care. In a perfectly functioning market we can rely on the market to weed out companies that are conducting themselves like the insurance companies do, but in the health care market, that isn't working.

Government doesn't work like that. Government has to be liked. If a majority of people think it is doing a bad job, then we vote somebody else in. That is a much less precise control mechanism than the market is when it is working right, but it is still way better than a broken market.

Neomalthusian said:

And you think the government is altruistic? The only rational way to address the artificial inflexibility of demand is to let it become flexible again. That means to only give people what they themselves directly pay for. No one with a $30k/yr income would pay $1,000 a day for a pill, do you know why? Because it's impossible for him to. No one will lend a guy that sort of money either. And so do you know what happens next? The company doesn't make any money on their $1,000/day medication, so it has to find a way to drop prices to levels where people would actually pay for them.

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We're a first world country. There is no reason we need to be making people go without something as basic as health care just because they're poor. Even most third world countries don't do that.

But, we do need to cut out some of the most absurdly expensive treatments. If private insurance companies want to cover them, that's fine of course, but IMO the public option should try to be pretty modest in what extravagant treatments it covers. $1,000 a day, if it is needed to save a life, that's fine, but $100 k for a procedure with a 15% chance of curing a non-life threatening condition or something, that should be left to private insurance IMO.

teamosil said:

Correct.



Again, the benefits come from having an entity that isn't trying to extract profit from it's customers that is big enough to push harder on prices in the game.



Well, first off, if it doesn't manage to push prices down better than the insurance companies do, then no harm would be done. People just wouldn't use the public option if it cost more.

But, again, in every country in the world that has adopted it, the public option or single payer has managed to negotiate prices down much more effectively than the private insurance companies have. For example, if some company makes a new medication and they want to sell it for $150 a pill, and they sell it to all the insurance companies at the same price, then it doesn't hurt them to carry it. They just jack up their prices enough to cover it and add on a nice fat markup and all the other companies do the same, so they aren't giving up any competitive advantage. Heck, the more expensive it is, the more room there is for markup. They can screw us over like crazy and it doesn't matter. We still need what they have. Everybody hates the insurance companies, but that has no effect on them.

Companies can't do that in a normal industry where the consumers are picking the products to buy and are well informed, but like I discussed earlier, that isn't the case in health care. In a perfectly functioning market we can rely on the market to weed out companies that are conducting themselves like the insurance companies do, but in the health care market, that isn't working.

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It would work if we let companies price their customers right out of the game. If they can't control the costs of what they reimburse and people stop being able to afford the premiums, they lose their customers and face the same fate as other failed businesses. If you leave the market alone, all unaffordable services rot out of the system because no one rewards unaffordability.

Government doesn't work like that. Government has to be liked. If a majority of people think it is doing a bad job, then we vote somebody else in. That is a much less precise control mechanism than the market is when it is working right, but it is still way better than a broken market.

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The market isn't broken if you just let it do what it does. There's nothing to break. It self-regulates. Health insurance is not a free market type of setup. It's a very communistic type of set up in that it pools a resource based on ability and dispenses it based on need. A free market would suppress prices by making unaffordable services economically non-viable (the provider of something unaffordable doesn't attract any customers, because no one can afford it). The winners in health care would be those who provide the best services at the most affordable prices so that the most amount of people can just pay for what it is they want or need.

We're a first world country. There is no reason we need to be making people go without something as basic as health care just because they're poor. Even most third world countries don't do that.

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You're going to contradict yourself pretty soon. See below.

But, we do need to cut out some of the most absurdly expensive treatments. If private insurance companies want to cover them, that's fine of course,

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Except that we are federally mandated to be their customers now, so no, it's not fine.

but IMO the public option should try to be pretty modest in what extravagant treatments it covers. $1,000 a day, if it is needed to save a life, that's fine,

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What about $5,000 a day?

but $100 k for a procedure with a 15% chance of curing a non-life threatening condition or something, that should be left to private insurance IMO.

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Haha, cue the appeals to pity (e.g. "what if it were your child, oh god the humanity!!"). What if private insurance can't cover that extravagance? I thought we were a first world country that does not deny medical care on the basis of ability to pay?

Neomalthusian said:

It would work if we let companies price their customers right out of the game. If they can't control the costs of what they reimburse and people stop being able to afford the premiums, they lose their customers and face the same fate as other failed businesses. If you leave the market alone, all unaffordable services rot out of the system because no one rewards unaffordability.

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No, that's incorrect. If you just let insurance companies price their customers out of the game- which is essentially what we do- they do exactly what they are doing. They try to maximize their profits. In a market where everybody is perfectly informed and the consumer is making decisions about what products to buy based on price and quality and all that, competition over prices will force prices down to match cost, approaching the point where there is maximum efficiencey and zero profits. But we don't have a market like that in health care, so that isn't happening. Without the check the market would ideally provide, in a market where the demand is inelastic, the way companies maximize profits is by setting prices extremely high and doing very few transactions.

Imagine that you produce 10 insulin pills a day and you're in charge of setting the price you want to sell them for. There are 10 people who need insulin to live. All of them are willing to pay every penny they have on insulin. 9 of those people have a maximum of $500 per day, the 10th can pull together $6,000 a day. What price would you set for the insulin to maximize your profits?

The answer is that you maximize profits by setting the price at $6,000 per day, throw away 9 of the pills each day and let 9 people die. That way you get $6,000 per day. You could sell all 10 pills each for $500, so everybody could get one, but then you'd only get $5,000 per day.

teamosil said:

I'm getting the sense you may be unclear on how the public option works. It isn't paid for by either taxes or borrowing. It is a service that you guy. It's customers would be people who chose between a private insurance company and the public insurance company. They would make payments to it for that service just like they do to a private insurance company.

I honestly don't get why the tea party got so outraged about it. If they don't want to us a public option, they could just continue using private insurers. But they didn't want anybody to have that option for some reason... Mostly to do with conspiracy theories I think.



I don't really get where you're coming from with the "too complicated" angle. Life is complicated. If we want to talk about life, it is going to be complicated.



I think I already covered that. The public option could negotiate harder than individual insurance companies and would eliminate the costs of profit taking.

A lot of what is wrong with our health care costs is basically extortion. Health care is fairly inelastic- meaning that people will buy it at any price. If you need a pill to keep you alive, you'll pay anything up to all you have and all you can borrow to get it. The people who make those pills know that. We need a much better, more altruistic, more powerful, entity representing us.



Maybe you have. I am nowhere near ready to give up on the country. We need to fix it.

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We now have two "public options" Medicare and Medicaid and they are both experiencing massive fraud and huge "per patient" costs, yet NEITHER was removed by (or included in) PPACA. PPACA mandates "fairness" (political correctness?) by not allowing the use of sensible and rational actuarial statistics to set medical care insurance premium rates. PPACA allows only age and smoking to be used to set premium rates, when we all know that gender, ALL recreational drug use and obesity make sense to consider.

PPACA also eliminates the use of "catastrophic" coverage for those over 30 years of age and adds MANY "first dollar" mandates turning insurance into a "give away" program no longer subject to ANY deductable. It seems that whenever the gov't gets involved they want to "fix" things by appealing to favorite voter groups (women and the obese) rather than REALLY concentrate on honest evaluation of RISK, the necessary basis for running ANY insurance operation.

Insurance should be used ONLY for the rare, the unexpected and the expensive and NOT used as a substitute for a NORMAL private household budget. BC pills (and other NON-CONDEM contraception) being the perfect example, as they are used ONLY by females, are relatively inexpensive and have NOTHING to do with any "illness", yet they are made into a centerpiece of political correctness; basically being made into a "right" to be PAID FOR only by those that DO NOT use them. USA, USA, USA...

Neomalthusian said:

The longer I spend reading and debating about this, the more convinced I am that, if we want financial sustainability in health care, we have to go all-or-nothing. Either cash-only abolish insurance which would be associated with dropping prices right away. No one likes this because death is unacceptable, and because being on your own causes you to save money, and our government does not want us to save money, they want us to spend it all, and then some. So if we don't take that approach, we need a full government takeover of the industry.

Government is going to continually claw for ways to restrain price increases, but everything is escapable. The 80/20 rule? It encourages rising premiums (because the more you charge-and-spend, the more you keep). The pre-existing condition rule, the 26-year-old children rule? Payouts explode, so shave benefits wherever you can and raise premiums. Not allowed to raise premiums more than 10% a year? Raise them 9.9% a year. People are not allowed to "opt out," but can't afford to opt in? Opt out anyway and forego the tax refund. Finally put in place every last control you can, every last mandate and restriction and cap on insurance companies, and it's financially nonviable? Then what? Victory is ours? No, the company folds and goes out of business. It is completely impossible to chase everyone around and try and force them to behave in contrived economic way, unless you abolish any private aspect about it all becomes the United States Department of Health Care. Private businesses and consumers will all find their way around every regulation until government completely takes them over, sets wages, sets reimbursement rates, the whole nine yards.

There really can be no freedom in this industry if we want all the care we need to be both provided and paid for. We either have government destroy choice and control everything, or we decide to control nothing and let people make their own decisions about saving money for health care or accepting the consequence that they won't get what they won't pay for.

The worst worst worst thing government could do is maximize access and not control costs. PPACA has done exactly that. Maximizes access, fails to control costs. And liberals seem to hint that they understand this, and see it as progress anyway, because if it makes the problem worse fast enough, we'll have to overhaul it even more.

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First, medicine will fight doing away with third party payers. They know they will have to shrink the profession, cut out a lot of business, and deal mostly with only the very wealthly. Most will never be able to afford any serious need. And office visits will just not be profitable effort to cover the need.

And many here will fight UHC.

That's why we get crap bills like the one we have. It's a step, but real reform is hindered by the two realities.

Boo Radley said:

First, medicine will fight doing away with third party payers. They know they will have to shrink the profession, cut out a lot of business, and deal mostly with only the very wealthly. Most will never be able to afford any serious need. And office visits will just not be profitable effort to cover the need.

And many here will fight UHC.

That's why we get crap bills like the one we have. It's a step, but real reform is hindered by the two realities.

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NONSENSE. Look at education, that has costs rising FASTER than medical care, yet is nearly 100% gov't owned and operated. The major "third party" involved in education is the student loan (and grant) racket, which is LARGELY gov't controlled, guaranteed and allows the actual price to NOT be any real consideration; just as when you "buy" a house, you look at the monthly "projected" loan payments, NOT the actual cost of the property. THIS year the taxpayers are subsidizing "student loan" INTEREST for about $6 BILLION for no rational reason at all (except tradition).

Student Loan Subsidies Benefit Elites at Taxpayers

Higher Education Subsidies | Downsizing the Federal Government

ttwtt78640 said:

We now have two "public options" Medicare and Medicaid and they are both experiencing massive fraud and huge "per patient" costs

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Medicare are for people with disabilities and the elderly.... Of course their cost per patient is way higher than the average persons. But actually both of them have overhead costs that are a small fraction of what private insurance companies waste on overhead.

ttwtt78640 said:

PPACA mandates "fairness" (political correctness?) by not allowing the use of sensible and rational actuarial statistics to set medical care insurance premium rates. PPACA allows only age and smoking to be used to set premium rates, when we all know that gender, ALL recreational drug use and obesity make sense to consider.

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Insurance companies never set rates based on obesity or drug use, so what this one is really about is gender. You tell me, why should women pay more?

ttwtt78640 said:

PPACA also eliminates the use of "catastrophic" coverage for those over 30 years of age and adds MANY "first dollar" mandates turning insurance into a "give away" program no longer subject to ANY deductable.

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They didn't eliminate it, it just doesn't count as sufficient to evade the penalty. And it shouldn't. One of the main points of all this is to remove barriers to people getting preventative care instead of waiting until things turn into catastrophes that cost 100 times as much to fix.

Who is committing all the "massive fraud"? Could it be the private providers, stealing from the taxpayers?

teamosil said:

Medicare are for people with disabilities and the elderly.... Of course their cost per patient is way higher than the average persons. But actually both of them have overhead costs that are a small fraction of what private insurance companies waste on overhead.

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I understand what Medicare/Medicaid/CHIP are but why have three gov't medical care programs (plus the VA) and then add PPACA? This is how gov't always works; add, add and then add some more. Instead of sitting back and looking at the whole picture, gov't tends to whittle away at bits and pieces, then trys to fix the bits and pieces that always get broken along the way. Many of those added to PPACA are simply by extension of Medicaid but with a 2% of income "co-pay". Medicare is now half private and half public, just like PPACA yet was not included only to keep the insurance companies happy by keeping all of the old folks out of "their" pool.

teamosil said:

Insurance companies never set rates based on obesity or drug use, so what this one is really about is gender. You tell me, why should women pay more?

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Gender is used as a risk factor in life and automobile insurance because it is actuarially significant. The reason women should pay more is because they incur higher medical care costs, the same reason that they should (and do) pay less for automobile insurance.

http://www.bazelon.org/LinkClick.aspx?fileticket=R9YQS4gzb44=&tabid=345

teamosil said:

They didn't eliminate it, it just doesn't count as sufficient to evade the penalty. And it shouldn't. One of the main points of all this is to remove barriers to people getting preventative care instead of waiting until things turn into catastrophes that cost 100 times as much to fix.

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There is no "barrier" to getting preventive care just because it is not free or heaviliy subsidized by insurance. People maintain their homes and vehicles without using their homeowner's or auto insurance policies to do so. They simply budget for these normal household and transportation expenses just as they do for their routine health maitanence care.

Insurance is for the rare, the unextected and the expensive events, not for everyday maintanence costs; this is true in all areas except for medical care. The PPACA makes this even more so by mandating many additional "no out of pockect" items; in other words, if you do not use these PPACA "freebies", in every year that you must pay for them, then you are a moron. This will mean that many people which feel fine will now likely schedule those "free" PPACA mandated appointments simply because they are now "free".

We are aware of a "doctor shortage" yet pass laws that virtually mandate extra unnecessary doctor visits simply out of the hope that a few "needy" folks will get seen that otherwise would not, based on their "savings" of the deductable/co-pay. The falacy, of course, is that "free" diagnosis does not mean that you get "free" care, so any follow up, for actual treatment, is still just as costly (and impossible) as before since the poor have no money for the deductable/co-pay for the actual treatment visits or any medications prescribed.

ttwtt78640 said:

I understand what Medicare/Medicaid/CHIP are but why have three gov't medical care programs (plus the VA) and then add PPACA? This is how gov't always works; add, add and then add some more. Instead of sitting back and looking at the whole picture, gov't tends to whittle away at bits and pieces, then trys to fix the bits and pieces that always get broken along the way. Many of those added to PPACA are simply by extension of Medicaid but with a 2% of income "co-pay". Medicare is now half private and half public, just like PPACA yet was not included only to keep the insurance companies happy by keeping all of the old folks out of "their" pool.

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Why would we get rid of them? If we had a public option and just rolled in medicare and medicaid to it, I'd be fine with that, but since medicare is more efficient than the private insurers it doesn't make sense to get rid of it absent a public option IMO. It would just end up costing more for no benefit.

ttwtt78640 said:

Gender is used as a risk factor in life and automobile insurance because it is actuarially significant. The reason women should pay more is because they incur higher medical care costs, the same reason that they should (and do) pay less for automobile insurance.

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Those aren't comparable. Men pay more for car insurance because they drive more and they drive less cautiously. Those are things we want to discourage.

Women were paying more for insurance because they get more preventative care, which we want to encourage, not discourage, and because their reproductive systems are more expensive to provide care for, but we all have equal responsibility for that. We were all born from one of those expensive reproductive systems after all.

ttwtt78640 said:

There is no "barrier" to getting preventive care just because it is not free or heaviliy subsidized by insurance. People maintain their homes and vehicles without using their homeowner's or auto insurance policies to do so. They simply budget for these normal household and transportation expenses just as they do for their routine health maitanence care.

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Cost is a barrier. If we were having a national crisis somehow emerging from people not maintaining their homes enough, we'd want to look at ways to reduce that barrier.

The way the system was, and to some extent still is, it is set up to encourage people to wait for things to become catastrophic. That is a bad incentive. People should be encouraged to get preventative care because it is much cheaper. If anything, we should be penalizing those who get a catastrophic condition that could have been easily prevented, not penalizing those who seek that preventative care and then making them pay extra to cover the folks who waited.

ttwtt78640 said:

The PPACA makes this even more so by mandating many additional "no out of pockect" items; in other words, if you do not use these PPACA "freebies", in every year that you must pay for them, then you are a moron. This will mean that many people which feel fine will now likely schedule those "free" PPACA mandated appointments simply because they are now "free".

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They should! That would be awesome if people do that. It would save us tons of money, again, because preventative care is so much cheaper than waiting until things get really expensive to fix before they go in.

ttwtt78640 said:

We are aware of a "doctor shortage" yet pass laws that virtually mandate extra unnecessary doctor visits simply out of the hope that a few "needy" folks will get seen that otherwise would not, based on their "savings" of the deductable/co-pay

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The doctor shortage is mostly just a right wing fear tactic. The market adapts. If there is more demand for a given profession, then more people go into that profession because it has great career prospects.

LOL. You skipped right over that elephant in the room. How are the poor going to "afford" any more care if they have a $2,000 deductable before their "exchange" insurance policy kicks in?

ttwtt78640 said:

LOL. You skipped right over that elephant in the room. How are the poor going to "afford" any more care if they have a $2,000 deductable before their "exchange" insurance policy kicks in?

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That is the maximum deductible you're allowed to have and count it as insurance satisfying the requirement, not like a fixed deductible for all plans on the exchange or something. People can decide for themselves if they're comfortable having a deductible that high. But, yeah, somebody who finds out they have cancer or something is going to scrounge up $2,000 if they need to. But if you think the deductible limit should be lower, we could consider that... But before you were arguing the opposite. You wanted high deductible "catastrophic" coverage plans.

ttwtt78640 said:

NONSENSE. Look at education, that has costs rising FASTER than medical care, yet is nearly 100% gov't owned and operated. The major "third party" involved in education is the student loan (and grant) racket, which is LARGELY gov't controlled, guaranteed and allows the actual price to NOT be any real consideration; just as when you "buy" a house, you look at the monthly "projected" loan payments, NOT the actual cost of the property. THIS year the taxpayers are subsidizing "student loan" INTEREST for about $6 BILLION for no rational reason at all (except tradition).

Student Loan Subsidies Benefit Elites at Taxpayers

Higher Education Subsidies | Downsizing the Federal Government

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It is not remotely or any near 100% own. Nor is it comaprable to medicine. Private schools are far more predatory than state schools, which still take in private payers. No one has to take out a loan, and I know students who don't. And I know many who didn't and got taken by private predatory schools.

Anyway, none of that ahs anything to do with what I said. Re-read.

teamosil said:

That is the maximum deductible you're allowed to have and count it as insurance satisfying the requirement, not like a fixed deductible for all plans on the exchange or something. People can decide for themselves if they're comfortable having a deductible that high. But, yeah, somebody who finds out they have cancer or something is going to scrounge up $2,000 if they need to. But if you think the deductible limit should be lower, we could consider that... But before you were arguing the opposite. You wanted high deductible "catastrophic" coverage plans.

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You, again, are missing the point (and going in circles). You keep talking about the wonders of PPACA making things "free" but, of course, that is only possible via income redistribution. The poor (those making under $30K) will not get any "options"; they will get only what the insurance industry must give them (via the exchanges) and no more, since the taxpayers are paying most of the bill. As long as any deductable or co-pay exists it will not be a prioirity over a six pack or a movie. You place way too much faith in the "wisdom" of the uneducated and socially challenged. What wil happen, as it does with all social programs, is that the poor will keep getting more and more added to the PPACA "exchange" medical insurance package until it is indistinguisable from Medicaid (totally taxpayer supported). The reality is that the poor will never place medical care high on their priority list, all you have to do is look a Medicaid (which is free) and see that they do not seek "preventive" care at all, which is why its costs are so high. I see your point that IFF medical care was free then maybe more would use it "correctly" but that is never going to happen.

ttwtt78640 said:

You, again, are missing the point (and going in circles). You keep talking about the wonders of PPACA making things "free" but, of course, that is only possible via income redistribution. The poor (those making under $30K) will not get any "options"; they will get only what the insurance industry must give them (via the exchanges) and no more, since the taxpayers are paying most of the bill. As long as any deductable or co-pay exists it will not be a prioirity over a six pack or a movie. You place way too much faith in the "wisdom" of the uneducated and socially challenged. What wil happen, as it does with all social programs, is that the poor will keep getting more and more added to the PPACA "exchange" medical insurance package until it is indistinguisable from Medicaid (totally taxpayer supported). The reality is that the poor will never place medical care high on their priority list, all you have to do is look a Medicaid (which is free) and see that they do not seek "preventive" care at all, which is why its costs are so high. I see your point that IFF medical care was free then maybe more would use it "correctly" but that is never going to happen.

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You're kind of saying a lot of conflicting things. You are worried that too many people will seek preventative care and not enough at the same time. You are arguing that we should allow catastropic plans, but then a minute later arguing that high deductibles are bad. No offense, it has been a good discussion, but I kind of get the sense that you're just throwing out all the arguments you can think of to see what sticks.... That's fine, but don't make it out like I'm not responding to your arguments. I've responded directly to every one and you have dropped all of them but this one.

Do you have a source that says that people on Medicaid don't seek preventative care? To be on Medicaid you need to be disabled in most cases, so most folks on Medicaid are actually in and out of the hospital and seeing doctors many times a year, sometimes even multiple times a week, so I am very skeptical of that claim.

As for the poor not getting any options out of this, that just isn't true. The government gives people a subsidy based on their income that they can use towards any approved plan. That would include plans with $2,000 deductibles, but also plans with very low deductibles. Also, like you said, most of the preventative stuff is free, so the deductible isn't an issue there.

For the general "the poor are lazy and stupid" angle, obviously that is both offensive and false.

My question to all of the liberals on this thread. Who is going to actually treat these patients? We have a shortage of doctors, and many would consider quitting over public medicine. Free healthcare doesn't do you any good if you die waiting on an available doctor .

teamosil said:

The doctor shortage is mostly just a right wing fear tactic. The market adapts. If there is more demand for a given profession, then more people go into that profession because it has great career prospects.

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"Right wing fear tactic" is not a valid argument.

We have a doctor shortage. It's projected to get worse. I discussed this in my orginal post.

teamosil said:

Those aren't comparable. Men pay more for car insurance because they drive more and they drive less cautiously. Those are things we want to discourage.

Women were paying more for insurance because they get more preventative care, which we want to encourage, not discourage, and because their reproductive systems are more expensive to provide care for, but we all have equal responsibility for that. We were all born from one of those expensive reproductive systems after all.

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“Obese men rack up an additional $1,152 a year in medical spending, especially for hospitalizations and prescription drugs, Cawley and Chad Meyerhoefer of Lehigh University reported in January in the Journal of Health Economics. Obese women account for an extra $3,613 a year. Using data from 9,852 men (average BMI: 28) and 13,837 women (average BMI: 27) ages 20 to 64, among whom 28 percent were obese, the researchers found even higher costs among the uninsured: annual medical spending for an obese person was $3,271 compared with $512 for the non-obese.”

Obesity Now Costs Americans More In HealthCare Spending Than Smoking - Forbes

That doesn't sound like "expensive reproductive care" to me. This also leads into another point, we spend more on health insurance not because medicine is privitized, but because we are a fat country. Want to lower costs? Fix our obesity problem. Obviously that $3,271 per person isn't doing much to curb the problem, so why would we do more of the same?

teamosil said:

Cost is a barrier. If we were having a national crisis somehow emerging from people not maintaining their homes enough, we'd want to look at ways to reduce that barrier.

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ACA hardly curbs costs. If anything, it could make it worse by giving potentially less doctors 30M new patients. (See my orginal post.) Cost is obviously a barrier, but the ACA wasn't designed to lower costs. It was designed to pay for the uninsured by deflecting costs.

ReformCollege said:

“Obese men rack up an additional $1,152 a year in medical spending, especially for hospitalizations and prescription drugs, Cawley and Chad Meyerhoefer of Lehigh University reported in January in the Journal of Health Economics. Obese women account for an extra $3,613 a year. Using data from 9,852 men (average BMI: 28) and 13,837 women (average BMI: 27) ages 20 to 64, among whom 28 percent were obese, the researchers found even higher costs among the uninsured: annual medical spending for an obese person was $3,271 compared with $512 for the non-obese.”

Obesity Now Costs Americans More In HealthCare Spending Than Smoking - Forbes

That doesn't sound like "expensive reproductive care" to me. This also leads into another point, we spend more on health insurance not because medicine is privitized, but because we are a fat country. Want to lower costs? Fix our obesity problem. Obviously that $3,271 per person isn't doing much to curb the problem, so why would we do more of the same?

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No doubt. I definitely agree with that. IMO insurance should cost more for the obese and we should be taking other steps to address it like education, maybe even do something about portion sizes.

ReformCollege said:

ACA hardly curbs costs. If anything, it could make it worse by giving potentially less doctors 30M new patients. (See my orginal post.) Cost is obviously a barrier, but the ACA wasn't designed to lower costs. It was designed to pay for the uninsured by deflecting costs.

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Right. The public option was the part that was designed to curb costs. What the ACA does is remove the cost problem for people who can't afford it by shifting it around to people who can, but without the public option it doesn't do anything to address the overall problem of rising costs. We still need to implement the public option. But, at least for now nobody has to go without medical care while we get the political issues worked out.

teamosil said:

No doubt. I definitely agree with that. IMO insurance should cost more for the obese

What the ACA does is remove the cost problem for people who can't afford it by shifting it around to people who can, but without the public option it doesn't do anything to address the overall problem of rising costs.

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ACA says that you can't set premiums based on health status. So we are both in agreement that the ACA fails in this regard.

Just because someone can't afford to be fat, doesn't mean I should pay for it. I'm sure anyone can afford the $512/year. I'll say it's a little ironic when you say that the obese should pay more for health insurance, but the poor should pay less. These two demographics have a ton of overlap.

It's not about what someone can afford to pay, its about what it costs. Individuals should bear the cost burden of their health decisions, and that should be a fundamental law. What reform should be focused on, is lowering the overall cost of each of those health decisions, and attempting to remove built in costs from other peoples decisions. For instance, abusing ER care by those without insurance.

"Dr. Jeff Thompson, chief medical officer for Washington’s Medicaid program, said the state is committed to paying for medically necessary care. But many times, he said, patients go to ERs when they would get better, and less expensive, care in a primary-care ‘medical home.’

‘The ER cannot be the medical home of the 21st century,’ he said. ‘We will not pay for diaper rash treated in the emergency room.’

Some patients show up as many as 120 times a year for costs of $20,000 to $25,000, he said, but until now, most ER doctors and hospitals have done little to deter them because the state paid the bills.

‘The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER,’ Thompson said."


This is an extremely easy and obvious fix, you simply state that ER's can reject non-emergency care regardless of ability to pay. We have to be human, so we can still give individuals emergency care even if they can't pay, but going to the ER for a runny nose and oh by the way could you give me all my vaccines is a huge burden on the insured. The poor aren't getting the shaft here, they already receive free health care coverage from Medicaid, and they completely abuse the ER. If you want to know why ER waiting hours are so long, this is why.

Sure, price will always play as a barrier to access. But I will always advocate lowering that barrier for everyone, rather than giving certain individuals a short cut through the barrier, while leaving it the same height, or a greater height, for everyone else.

I discuss how to lower this barrier in my original post, but I'll add to my ideas.

1. We need more doctors and nurse practitioners, (and really everyone in the medical field.) If you want the poor to have equal access to health insurance, we have to have the medical professionals who can carry that level of capacity. If we don't then there simply is no way we can give health care to someone without taking it from someone else.

2. I support snatching the "state's rights" on the issue, and making health care guidelines nationally mandated. Allow individuals to purchase health insurance from anywhere in the country. Competition will drive down profits, and prices, of insurance companies.

3. Tort reform. It's only 6% of direct costs, but speaking with workers in the health care industry, it has a lot to do with how hospitals run and operate. For instance, testing for a genetic disorder that happens in 1 out of 10,000 cases with particular symptoms, for every single patient with those symptoms in order to avoid a lawsuit. It's frivolous. Imposing a flat maximum reward isn't right either. We need to clean up our guidelines for when and when a hospital is not liable for failing to test for a disease. Also, I think it would be beneficial to limit "emotional suffering" penalties to a percentage of hospital bills.

4. The mandate is something I actually support. Just not as the system currently stands. It currently is just a way to force young, relatively healthy workers, into the system to pay for older, less healthy individuals. Perhaps if we did have a system for setting rates based on health factors, which we should but the ACA prevents, then a mandate would be a good thing.

5. Doctors need to be paid a salary. Or the current fee based system could work, but only if they are paid based on treatment not based on how many tests they run.