Health Insurance Isn’t Really Insurance At All

The health insurance system in the United States is broken. But you already know that. What you may not realize is why it is not only broken, but in many ways is not fixable. At least not without changing some of our fundamental beliefs about how health insurance and our health care system should work.

To fully grasp this, let’s start by looking at insurance itself. Insurance exists because there are rare but ruinously expensive events that happen to people at unpredictable times. The purpose of insurance is to spread the risk of those rare but ruinously expensive events across a large enough group of people and a long enough time that the cost per person per unit of time becomes bearable. For most of the insured, this is a losing proposition. That is, even excluding administrative and profit costs, you are likely to spend more on insurance than you will receive in claims. The more catastrophic and rarer the insured event, the more likely this is true.

And yet we buy insurance anyway, mostly because the cost to us of the rare event is so great that we are unwilling to accept the consequences. This is completely rational and expected behavior. There’s an entire article that can be devoted to a discussion of how insurance relates to the spectrum of people from risk-averse to risk-seeking, but that’s far more involved than necessary for this article. The Wikipedia article on risk aversion is quite good, though.

Now let’s look at health care. We treat it as if it were this monolithic beast, when in fact it consists of several loosely related separate parts. I’ll describe them here, and you’ll see what I mean.

Catastrophic external events: These are things like car crashes or earthquakes causing bookcases to fall on you. They’re essentially unpredictable, and the cases that matter most require expensive medical attention.

Catastrophic internal events: These are things like aggressive cancer or degenerative diseases. These are, to varying degrees, more predictable than the catastrophic external events, and many of these benefit from early diagnosis and treatment.

Chronic conditions: Asthma and some types of diabetes go here. Treatment of these is focused on the symptoms, as the underlying disease is not curable.

Communicable disease: I’m not counting things like the common cold. This is more about diseases for which treatment addresses the underlying disease and/or prevention of acquiring the disease in the first place.

General maintenance: This includes both asymptomatic and symptomatic checkups, where there is not a clear indication of a particular disease. Non-communicable infections and minor communicable diseases like the common cold also apply here. Basically, this is the stuff for which you go to a General Practitioner.

Elective services: Most cosmetic surgery falls under this category, but so do a few other things. There’s room for differences of opinion on many of these, such as gastric bypass.

One problem with insuring healthcare is the notion of a total loss. In traditional insurance, there is a known maximum value for an event. In the case of automobile insurance, there is a maximum liability in the policy, and collision will cover a maximum of the current value of the vehicle, at which point it is considered a “total loss.” Health insurance has attempted to accomplish a similar result with lifetime caps (which are no longer legal). But people are understandably squeamish about assigning a dollar value to their lives. Nobody wants to be told that they or their loved ones are going to die due to a lack of money. This immediately changes the insurance equation, because premiums need to be significantly higher if the policies have no caps on claims.

Another problem with insuring health care is most of the above categories don’t all fit well with the traditional notions of insurance. Catastrophic external events are the only sort of situations for which classic insurance is a perfect match. General maintenance would be silly to cover in the case of automobile insurance (imagine insurance covering oil changes), but for catastrophic internal events, the cost to the insurer is often significantly lower if discovered early, which means that it’s less expensive to cover general maintenance if it results in early discovery of catastrophic internal events. But general maintenance will rarely uncover these catastrophic internal events, so most of the money spent on general maintenance goes to areas not typically associated with insurance.

Of course, full coverage of general maintenance without co-pays tends to lead to the insured overusing medical services. If it’s free, there’s little incentive to err on the side of frugality. On the other hand, having co-pays tends to lead to the insured underusing medical services. Since many diseases are much less expensive to treat when they’re either asymptomatic or mildly symptomatic, people with co-pays are more likely to remain undiagnosed until the disease has progressed beyond the cheap-and-easy-to-treat stage. Since most Americans aren’t doctors, and since medicine is so complex today, few of us are able to adequately determine the ideal time to see doctors for diagnosis and treatment. Basically, general maintenance is simultaneously well-suited and poorly-suited to insurance.

Chronic conditions and elective services are badly matched to insurance. Chronic conditions tend to have relatively predictable costs, which are fairly constant over time (think asthma inhalers or birth control pills). Elective services are, by their very nature, entirely predictable, since they are entirely controlled by the person receiving the services. The necessary overhead of insurance makes coverage of chronic conditions and elective services more expensive than simply paying out of pocket. But many types of elective services are hard to distinguish from necessary treatments. At what point does reconstructive surgery become elective, for example?

Communicable diseases are worthwhile to insure against, but work best when everyone is covered. This is the same sort of situation as we have with fire protection (not fire insurance). Just as it is less expensive to put everyone’s fires out as quickly as possible than to have patchwork coverage, where some people are covered and others not, it is less expensive (and causes fewer deaths) to control communicable diseases as quickly as possible than to treat some people and leave others untreated. For communicable diseases, then, the best model is not insurance in the traditional sense, but rather universal coverage. Often these diseases are diagnosed at general maintenance appointments, further clouding the appropriateness of general maintenance coverage.

So, some healthcare is well suited to individual policies, some to universal coverage, and some to no coverage at all. And not all situations fall neatly into a single category, as evidenced by the bleedover between catastrophic internal and maintenance. Already it’s a mess. But it gets worse.

By far, the majority of Americans get their health insurance from their employers. This means that they have little or no choice about the coverage they receive, and from whom. Few of us have the luxury to choose our employer based on the specifics of the health insurance provided, and even if we did we probably would consider other factors to be more important anyway. It’s silly to be in that position in the first place. Imagine if the food we were allowed to eat was determined by the make of car we drive. Health coverage and employment are an equally absurd match, from a purely objective perspective. I am aware of the history behind it, but that hardly makes this model worthy of perpetuation.

Now, since most Americans don’t get to choose their health insurance providers, this means the providers have little incentive to please the consumers of their products. Instead, they need to please their consumers’ employers, and these employers’ needs may well be at odds with those of the insured. For example, an employer will typically want employees to be healthy, because healthy employees are more productive than unhealthy ones. However, once an employee has been diagnosed with a terminal degenerative disease, it is now in the best interest of the employer for the employee to not have the coverage at all, and furthermore to no longer be employed, because the employee has become a pure liability. Even an employee with, say, a child with muscular dystrophy would likely be a net liability to the employer.

In other words, we’re getting insurance for many things that aren’t well-suited to be insured, from companies that don’t need to satisfy us, paid for by people whose interests match ours, when they do, only by coincidence. Given that, it’s remarkable that our system works as well as it does!

And then we have some scenarios for which the current system is completely useless. For example, it has often been suggested from the right that young people (say, in their 20s) don’t need to be insured at all, or need only catastrophic coverage coupled with a Medical Savings Account (MSA). This presumes they will not be subject to catastrophic internal events. Granted, the likelihood of a catastrophic internal event is relatively low, but what is our plan for those cases where they occur? As I noted above, someone with catastrophic-only coverage + MSA is unlikely to go for maintenance, which makes the prognosis much worse and the cost much higher upon diagnosis of a catastrophic illness. Is a 22 year old going to be sufficiently well informed to decide the appropriate level of insurance? I’m not convinced anyone is, since humans are notoriously bad at gauging risk. But those in their 20s are particularly unlikely to have the financial wherewithal to survive even one such instance, fiscally speaking.

So what do we need to do in order to fix this? Anyone who says they know the answer is either misinformed or lying to you. There is no perfect solution, because medicine today is more complex and expensive than ever before, and we must make some hard choices. No matter what, we have to give up at least one of the following:

  • Emergency care for all, regardless of ability to pay
  • Maximizing the financial efficiency of medical care (i.e., most bang for the buck)
  • Universal coverage against communicable diseases
  • Affordable coverage
  • Coverage of all treatments, regardless of cost

What we’re left with is a choice of which of those bullets are most important. This is where the discussions should start, because which features you choose will quickly lead to the optimal solution for that set of features.

One issue we have as a nation is an inability to have honest tradeoff discussions. Often, the conversations devolve based on an assumption that there is an easy way out, that there is so much money being wasted that we can get everything we want if we just focused on improved efficiency. From personal experience, I have never seen someone present that argument without being intellectually lazy about it. That is, when pressed to explain precisely where the inefficiency resides, the amount of waste described is always orders of magnitude smaller than the amount needed in order to close the fiscal gap between where we are and where they want us to be.

For example, tort reform is often, especially from the right, described as a way of eliminating much waste from health care. But malpractice insurance costs have not risen over the past couple of decades, and elimination of all malpractice judgments (which I can’t imagine anyone endorsing) would reduce our medical expenses by only 2%. Similar issues arise when the left points the finger at insurance company profits. I’m not arguing that these aren’t worth looking at, but they are very, very small compared to the rise inhealth care costs over the past decade.

Similarly, what is commonly referred to as “defensive medicine” is far less tied to malpractice costs than it is to the “Coverage of all treatments, regardless of cost” bullet point. We want to make sure nothing is missed, and our doctors know this. Defensive medicine is the natural result when the direct cost to us, the consumers of medical services, is low relative to the actual cost of the testing (because insurance picks up most or all of the tab), and doctors want to keep us happy as patients, and doctors don’t lose any money if patients have more tests. The “system” (usually our employers, ultimately) bears the bulk of the costs, and we as patients get all of the benefits. Is this something we want to change? I know a couple of people who, due to defensive medicine, were diagnosed with cancer. Neither would have been correctly diagnosed without the defensive testing. Both of them would have died if they weren’t diagnosed until they were sufficiently symptomatic. While I recognize that this is anecdotal, I can’t help but wonder if any of us are so firm in our beliefs about cost reduction in healthcare that we are willing to die for those beliefs.

I’ll discuss possible solutions, and the Patient Protection and Affordable Care Act (commonly referred to as the “Health Care Reform Bill” or pejoratively as “ObamaCare”) in particular, in a future article. In the meantime, I’ll leave you with a few questions:


 

  • Which of the five bullet points are you willing to do without, and why?
  • Are you willing to accept fewer tests in exchange for lower insurance premiums, but at a cost of higher risk of death?
  • If you see inefficiencies in the system today, which ones are big enough to make a serious dent in the cost of medical care in the US if we addressed them?
  • Which of the categories of medical care should be provided by health insurance, and why?
  • Do you think health insurance should be provided by employers at all? Why or why not?

 

 

 


About Michael Weiss

Michael is now located at http://www.logarchism.com, along with Monotreme, filistro, and dcpetterson. Please make note of the new location.
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85 Responses to Health Insurance Isn’t Really Insurance At All

  1. Monotreme says:

    Wow, that was the most cogent and reasoned set of arguments regarding health care reform I’ve ever seen. Kudos to you.I’ll kick this off by answering your question. First, I want to rephrase it (but just a little).You ask:Which of the five bullet points are you willing to do without, and why?I’m not happy about it, but I would choose the last bullet point:Coverage of all treatments, regardless of costI hate that the state of medical science has come to this, but we can’t continue to pay hundreds of thousands of dollars in many cases to prolong a poor quality of life for a short period of time.I know it’s an anecdote, but I think my aunt’s case is illustrative. She’s 86, and in the end stages of Alzheimer Disease.She’s not oriented to person, place or time, so she’s truly demented. She barely recognizes me or my dad or my sister, her only living relatives. She has no connection whatsoever to her previous life, and lives very much in the moment.She is independently wealthy, and is paying $7K per month for round-the-clock nursing care. (Rather, we are paying it for her, as her medical and financial guardians.)That’s fine, because she saved the money and I’m happy to contribute it to the local economy and keep people employed. However, if she did not have the money on her own, could I really justify keeping her alive using tax dollars? Is that what the American people want?More than half of Medicare dollars are spent on patients who die within two months.I would be fine with that if we were talking about two months of quality life, but we all know that the more common instance is two months confined to a hospital bed.I can hear St. Sarah screaming “Death Panels!” and you know what? I don’t care. It’s the reality of our situation. I think we should be given the option, while we are still compos mentis, to choose the manner and means of our passing. We are doing everything we can to exercise substituted judgment in my aunt’s case, but I honestly don’t think this is what she would’ve wanted. As you’ve correctly pointed out, we as Americans are not good at having this discussion, but we need to have it just the same.

  2. Jean says:

    Michael,re: Do you think health insurance should be provided by employers at all? Why or why not?I work for a very large corporation, which translates into a large pool of folks needing health insurance coverage. So my company is able to negotiate a very reasonable rate for both the company and the employee. Since this is a larger group than a small business is, the large corporation is therefore in a better negotiating position.The logic of a public option or state health insurance exchanges, where individuals could go purchase health insurance coverage through a private insurance provider participating in the exchange, but by doing so becomes part of a larger group, just plain makes a lot of sense to me.

  3. Number Seven says:

    Great article. It will be amusing to see the trite wingers replies.

  4. Mr. Universe says:
  5. shortchain says:

    I’m with Monotreme, mostly. A glaring absence in the write-up, IMO, is that it isn’t clearly broken out what the function of government is in this matter. I would say that it is beyond obvious that we cannot afford to publicly pay for all care, and that is the standout problem.While it may appear cruel and heartless to toss in the towel and say, “you’re on your own”, the alternative is logically and financially indefensible, as recognized by the current insurance companies, all of whom have limitations on the amount of care.We should learn from the market where it makes sense, and, in this case, it does. Given that premise, the role of the collective “we” (government) is to set standards for insurance so that there won’t be unscrupulous companies offering fake insurance to take advantage of the innumerate and short-sighted, and, perhaps, offer truly catastrophic insurance for the people that fall through the cracks.I’ve seen some horror stories in my time where people have been kept alive for a quality of life I know they wouldn’t tolerate if they were fully able to choose. Once they are in the grips of the medical establishment, they cannot escape.One of the big things that government could do is spend some serious money improving the capability for diagnosis. This is one of the driving factors in medical costs, because (having been on the receiving end of the battery of tests they’ll do on you if you don’t diagnose easily) the response of the medical community to their failure to diagnose a problem is to throw money (AKA “further procedures”) at it.

  6. filistro says:

    @shortchain: I’ve seen some horror stories in my time where people have been kept alive for a quality of life I know they wouldn’t tolerate if they were fully able to choose. Once they are in the grips of the medical establishment, they cannot escape.Yet another in the long list of Things That Utterly Baffle Me (a list that seems to grow ever longer as I get older)America is the most overtly “Christian” nation on earth, as in the nation where people are, statistically, most likely to identify themselves as “born again”, with a strong belief in a benevolent personal God and an afterlife.Yet it is also a country that obsessively fears death and will employ any means (including bankrupting the nation) to delay inevitable death… even for only a couple of months.Also, the more fervent the faith, the more manic the demand to cling to ebbing “life”.. no matter the quality or the cost.Why do the faithful fear death? Damned if I know.

  7. mclever says:

    Of the five bullets, the one I would go without is bullet 2: “Maximizing the financial efficiency of medical care (i.e., most bang for the buck).”I just don’t think one can put a price on someone’s life, and I feel very strongly that emergency care, chronic care, communicable disease prevention, maintenance care, etc. should all be covered under whatever plan, regardless of the patient’s ability to pay. In other words, I want to cover as much as possible while making it as cheap as possible for the consumers. That means I won’t give up bullets 1, 3 or 4.I would want all procedures covered, no matter the cost (bullet 5), if it involves saving someone’s life or treating a chronic condition. There are some elective treatments that I feel strongly should be covered (birth control, vasectomies, etc), but I admit that I feel significant hesitancy about covering *all* elective procedures. Then, it becomes tricky in defining what is truly elective. For example, a breast cancer survivor who wants implants for a breast reconstruction should be covered, but the actress who wants to go from size B to DD, probably should pay for that herself. Where is the fuzzy line in between? Who gets to make that call? Defining the limits of which “elective” care options are covered is where I see the most difficulty. That is where I can see a two-tiered approach, where the “basic” plan that everyone has pays for emergency care, checkups, etc., while consumers who can afford it have the option of buying a “gap” plan that covers those elective procedures not covered under the basic plan. Even under such a model, I would want as much as possible under the basic plan.Because I think health care must be affordable, I also think co-pays should be as small as possible (or nothing), because the number of people who “abuse” free medical care is minimal. We can all come up with anecdotes, but the vast majority of us don’t want to waste time in a doctor’s office unless we’re really sick. I realize that my preference for low or nonexistent co-pays means I’m not “getting the most bang for the buck.” So, bullet 2 becomes the one I’d give up, but I wouldn’t give up entirely. I’d want to examine efficiencies in the medical community and look for ways to reduce costs within the system, but that wouldn’t be part of the healthcare coverage, that would be part of being responsible with managing healthcare for our nation’s citizens. The cost concessions I’m willing to make come mostly under bullet 5, by negotiating which elective procedures would be covered and when or why.

  8. filistro says:

    I live in Canada where (having just enjoyed our Thanksgiving dinners) we are all very thankful for our universal health care. Despite the apocryphal horror stories regularly ginned up by Republicans, I can affirm the Canadian system works well, is fairly applied, and keeps us overall healthier at lower cost to the nation. So, because I’m having a different experience, I won’t presume to answer Michael’s excellent questions. I do believe, in a general sense, that health care is going to be the final battleground for the coming war between science and religion.Science is increasing our knowledge and ability at a bewildering, exponential rate. There are now many things we can do to preserve and prolong life. The question is… just because we can… does that mean we must? Does it even mean we should?

  9. mclever says:

    Do I think employers should be providing health care coverage?Absolutely not! I understand the historical reasons for the linkage, but now it is no longer sensible. – People should not lose their medical coverage (or be expected to pay expensive COBRA rates) when they lose their job and are least likely to be able to afford it.- People should not be held “hostage” to their employer’s health coverage. An employee should be free to look for a new job without worrying that they’ll go without coverage (even briefly) if they decide to change jobs. This would improve the efficiency in the job market by giving people greater freedom to move about.- Taking the expense of health coverage away from employers would make American businesses more competitive in the global marketplace where foreign employers do not face the same costs.I’m sure I could think of more bullets, but that’s pretty much the highlights of why I don’t think businesses should be paying health care coverage for employees. We as a collective society should be absorbing those costs for the betterment of society as a whole. It’s better for business, and it’s better for the people, too.

  10. mclever says:

    Another aspect that I feel gets overlooked in the conversations regarding coverage is the provider side of the equation. We all talk about the consumers, affordability, covering the sick and hurting. But there are cost-drivers on the provider side that are contributing to our problems. When discussing “defensive medicine”, I generally trust the doctors’ judgment about what tests should be run. However, when financial interests are at stake, I wonder if the doctors’ judgment might get a little cloudy. If a doctor is referring you to get an MRI at another facility where he has no financial ties, then you probably need the MRI. However, if the doctor has his own MRI machine (or part ownership of one) and gets to charge you (or your insurance) for the MRI appointment time and the use of the machine, then he has a significant vested interest in ordering MRIs. The decision is no longer neutral for the doctor.Having Xrays, MRIs, etc. be more accessible is a good thing. It increases efficiency if I only have to go to one place for all of my diagnostics. However, when comparing the costs between places like the Mayo Clinic and high-end doctors who have tons of diagnostic equipment at their private disposal, the Mayo Clinic seems to provide better care at much less cost. It seems we should be willing to learn something here.Some would say that the “defensive” costs are so high because of liability. Well, we can all argue about tort reform, but liability premiums are an objectively less significant factor in the total cost of care. Furthermore, if there are treatment guidelines and the doctor follows those guidelines, then there’s less risk of being sued for things. Therefore, the establishment of such treatment or diagnostic guidelines could have the overall effect of reducing doctor liability without formal tort reform.The key would be to look at the low-cost but effective models (Mayo Clinic is a prime example, but there’s a hospital in Arizona that’s good, too.) and emulate those on a broader scale. This isn’t part of a coverage discussion necessarily, but it is part of the total cost to our country.

  11. DC Petterson says:

    Michael:An excellent article! I want to comment on one point:Similar issues arise when the left points the finger at insurance company profits. I’m not arguing that these aren’t worth looking at, but they are very, very small compared to the rise inhealth care costs over the past decade.This is certainly reasonable. However, this is often confused with two related factors.1) Insurance companies tend to be inefficient, much less efficient thay, say, Medicare or the VA. Traditionally, only about 70% – 80% of insurance premiums go to pay medical costs (the new HCR bill now requires this number to be 85%). The rest goes to salaries, stock dividends, and various other corporate waste and inefficiencies. In contrast, the Medicare overhead is ony about 2%. It isn’t the profits that cause these inefficiencies per se. It is the fact that insurance companies are profit-driven rather designed for the benefit of customers.2) The fact that insurance companies are profit-driven also means they try to reduce payments, or avoid making payments completly, whenever possible. Their goal is not to maximize health outcomes, but to maximize profit — which means to minimize the amount of money actually spent on health care, since every dollar spent on care means a dollar less that goes to employees and shareholders. Further, most companies today are run for short-term goals rather than long term goals. This means there is no bottom-line immediate benefit to preventative care, as contrasted with catastrophic care with payment caps. All this leads to poorer outcomes at greater cost to the consumer.So the problem isn’t the profit itself, so much as the profit motive.

  12. DC Petterson says:

    shrinkers, did you throw your book at the President?🙂 ! No, not me. I’m a lot older than that guy.

  13. filistro says:

    Mr U… I’ve always been interested in the Oregon model for health care reform… it just seems so sensible.How is it viewed in-state?

  14. shortchain says:

    Oh, and yeah, there is no way that health insurance — or whatever it is — should be bound up in the employer/employee relationship. That was an unintended consequence of price controls long ago, and should be removed entirely. It does nothing but confuse the situation and hide the actual relationship.Having been through the mill a few times, I’m in a position to point out that “defensive medicine” may cost a lot, but if it’s your life on the line you tend to go along with the experts. That is, after all, why you went to them in the first place.So you go in with chest pains that come and go. What do you want them to do?a) tell you “It’s probably indigestion. Stay away from coffee, chocolate, carbonated beverages, spicy foods, and we’ll see if it gets better of the next few months.”b) tell you “It’s heartburn or perhaps an ulcer. Here’s two weeks’ supply of prilosec(tm) (or the OTC version), give us some blood, and we’ll see you for follow-up in a month unless it comes back positive.”c) tell you both of the above, but also “It’s almost certainly not a heart-attack or cancer, but we’re going to schedule you for an ultrasound and a cardio exam, because we’d like to make sure you don’t drop dead while we’re figuring out what it is.”Now, if you live in Canada, you are likely to get a) or b) and be just fine. If you live in any of the areas in the USA infested with forward-thinking medical care (yes, that’s sarcasm), you’ll get a), b), and c) and it won’t stop there. They’ll do everything but turn you inside out.This isn’t defensive medicine. They don’t do it because they are afraid you’ll sue if they missed something (the probability of the missed condition is extremely low, for one thing). No, they do it because they can. Insurance will pay for these things if the doctor says they’re a good idea, and the doctor, who has all the equipment (toys) and colleagues (friends) with even more toys has a proclivity to want to use them.Think “military-industrial complex” with scalpels and endoscopes, and be afraid. Be very afraid.

  15. Michael Weiss says:

    See? Monotreme and mclever both have very different notions about what health care should look like. I suspect if we got five people in a room, we’d have at least seven different opinions on this. It’s complicated.@Monotreme, you seem to be suggesting that people should be able to choose for themselves how much they want to prolong their own lives. That’s certainly fine as long as it’s on their own dime, but should we be doing this for everyone, even if it’s not on their own dime? To do so would go against your preference of dropping the “at all costs” bullet.@mclever, are you suggesting that you’d be willing to pay a billion dollars to keep someone on life support for an additional day? Or is there some upper bound to “at all costs?” Also, you say that “the number of people who ‘abuse’ free medical care is minimal.” Do you know this to be true, or do you believe this to be true? I haven’t seen any studies that answer this question, and I’m far less confident than you seem to be about it. I do agree with you that we should work to avoid conflicts of interest, where the doctor benefits financially from additional procedures. This should be relatively easy to legislate, though it might be difficult to enforce.@DC, I wanted to stay out of the efficiency discussion, because I’m not convinced that the inefficiency is necessarily a function of the profit motive. It could just as easily be an artifact of the insurance companies being beholden to the insured’s employers, rather than the insured.You’re right that most American companies today are run for short-term goals, and this could push them to focus on reduction of preventive care. A compounding factor is that people change jobs so often now that it is reasonable to expect that the catastrophic payment will come from some other company’s policy.@filistro, one of the issues that arises when you go down the “just because we can, does it mean we must” path is…who gets to decide where we draw the line? People in the US are very attached to personal choice. Having someone else decide for you where that line gets drawn will draw the ire of many. It’s not a topic that is easy to discuss without people getting riled up.

  16. Monotreme says:

    @Michael,You paraphrased my post thusly:@Monotreme, you seem to be suggesting that people should be able to choose for themselves how much they want to prolong their own lives. Not wrong, just not exactly what I meant to say.The payer (in my ideal example, the government) gets to set a boundary: we will pay for care up to this point, but no further.Beyond that, if the patient wants to pay privately, they certainly may; if they don’t want to, then they can choose a dignified exit.

  17. filistro says:

    @shortchain Now, if you live in Canada, you are likely to get a) or b) and be just fineActually, not.I live in Canada, in a small city in a mostly rural area.In 2005, somebody dear to me suddenly began having a slightly irregualr heartbeat and mild chest pains… surprising to us because he is normally so healthy. We went to ER and when we described the symptoms he was admitted immediately and put on cardio bed where his heartbeat was monitored for 4 hours. When nothing conclusive turned up, he was referred to a local cardiologist and scheduled over the next two weeks for three treadmill tests, an ultrasound and a barium X-ray.Still nothing definitive.. just a slightly irregular heartbeat and intermittent pain.. so he was referred to a cardiac unit in the nearest large city but during the two- week waiting time the symptoms began to resolve spontaneously, and were ultimately determined to have been caused by an infection that attacked the pericardium.Everybody I know here personally has the same experience. Any condition that could be potentially serious or life-threatening is tested/treated immediately and aggressively.

  18. Jeff says:

    Monotreme wrote:Wow, that was the most cogent and reasoned set of arguments regarding health care reform I’ve ever seen. Kudos to you.=============Let me join in the kudos. GREAT Job.Monotreme also said:More than half of Medicare dollars are spent on patients who die within two months. I would be fine with that if we were talking about two months of quality life, but we all know that the more common instance is two months confined to a hospital bed.===========The problem is knowing when there’s only two months left. I went through this with my 83 year old father, who lasted almost exactly two months from the day he fell and hit his head, until the day I approved taking him off life support.Until literally his very last 24 hours, the doctors never said that he wouldn’t make it. In fact, he was briefly discharged to a nursing home.One of the most painful periods of my life was the two months I commuted between California and Florida, watching him in a hospital bed. If I had known the outcome (and if HE had known the outcome), we never would have put him thru the wringer. He had a living will, and had repeatedly said he didn’t want to be kept alive if he wasn’t going to be able have a decent quality of life.I don’t begrudge the money — he had always been a fitness fanatic and there was every reason for me to have hope that he’d emerge and be good for another 10 years. The point is that you just can’t tell. And although I suspect the doctors know, they have to deal with the Hippocratic Oath as well as the uncertainty.I agree that if we could just tell when there were only the two months left, that both society and the individual would be far happier letting the person go, but there’s no way of knowing. At age 88 my father-in-law, in the course of two or three days, had several major heart attacks. He had massive medical intervention that probably cost about the same as my father’s. Today he’s 93. He’s frail, but totally sound of mind, and has great-grandchildren who he adores, and who adore him. With hindsight, it was wrong to keep my father going, and right for my father-in-law, but how can you know? And on balance, if I was going to err, it would be in favor of doing too much, not too little.And that’s where I have a problem with the UK’s national health service, which allows treatment only if the cost of the expected added lifespan is less than a given amount.

  19. filistro says:

    @Michael.. Having someone else decide for you where that line gets drawn will draw the ire of many. It’s not a topic that is easy to discuss without people getting riled up.Yes, I know. That’s what I understand lies at the center of the Oregon experiment… an attempt to put the guidelines on paper so they’re understood by everybody and (hopefully) separated from raw emotion. I’m curious how it’s working… because whether we like it or not, it’s soon going to be necessary.

  20. DC Petterson says:

    And that’s where I have a problem with the UK’s national health service, which allows treatment only if the cost of the expected added lifespan is less than a given amount.This is a legitimate concern, certainly. But since the average expected lifespan in the UK is greater than in the US, I’d say there is something right with their system, and perhaps this consideration, in the context of their entire health care approach, is not as draconian as it seems in isolation.It is, after all, important to keep everything in context.

  21. mclever says:

    Michael, there probably is an upper bound to “at all costs”, but I’m not qualified to draw the line myself. I think it’s a very difficult line to draw, as I indicated in my previous comment regarding when a treatment becomes “elective” vs. “necessary” or even “prudent.” Emotionally I want no expenses to be spared ever, but I can be talked back from that precipice with reasonable arguments for why some limits are appropriate in some cases. For example, I might be amenable to something along the lines of what Monotreme is suggesting, though I’d probably want the ‘basic’ coverage to cover more than he would. An example might be that once three separate doctors have concluded independently that the patient is in a permanent vegetative state, then perhaps the cost of continued life support should be considered ‘above and beyond’ or ‘elective’ and transferred back to the family and/or their supplemental plan. However, in many cases, there’s still hope for recovery until the last day or two of life, so the line isn’t easy to draw in cases where there’s still hope.Consider the case of Verna Schrombeck, who got a mechanical heart in 2007. She was probably a week or two from death due to imminent heart failure, and now she’s playing with great-grandkids and teaching piano lessons. Should we have deprived her of the past three years, because doctors in 2007 thought she had no time left? Or, should her mechanical heart (which was experimental at the time) be covered?

  22. Michael Weiss says:

    @DC, I advise caution when looking at average expected lifespan. If you put me in a room with Bill Gates, the average net worth of the people in the room is about $20B. That hardly makes me richer, though.Much of what makes the difference in average lifespan has to do with what happens to people in the early years of life, not the later ones.And to Jeff’s point, I personally knew someone who was diagnosed with an aggressive form of cancer in 1965 and was given a prognosis of 6 months to live. He got treatment anyway, and lived an additional two decades. He died of a stroke, and probably would have lived quite a bit longer had they not taken so long to diagnose him in the first place.Under the expected lifespan model, he would have died before 1966 due to lack of treatment.It’s all anecdotal, of course, but medicine is something so deeply personal that everything is anecdotal.

  23. mclever says:

    Michael, regarding co-pays:I originally believed as you do, because common sense says that people will abuse things if they’re free. However, I read a study of doctors’ visits by patients in California, and it tried to examine the impact of co-pays. Both patients and doctors were surveyed. From that study, higher co-pays ($25-$50+) did result in reduced doctor visits, but most of those arguably should have gone to the doctor and didn’t because the cost was prohibitive. Intermediate co-pays ($10-$20) still prevented some people from seeking care due to the cost, but not as many. Low co-pays ($5 or less) resulted in more people seeking care, but there were still some who refused to seek care even when the cost was nothing. At all three levels of co-pay, there were “abusers” who would visit the doctor multiple times unnecessarily. The frequency and number of abuses surprisingly did NOT appreciably decline with higher co-pays. Basically, if someone is a hypochondriac, they’ll visit the doctor no matter the cost, so raising or lowering co-pays has negligible impact on this behavior.I tried to search for that study, but couldn’t find it online. I don’t remember who did it anymore, because it was rather long ago that I read it. I remember it, because the result surprised me.

  24. filistro says:

    More questions about what “health insurance” should cover:Should a person who weighs 400 pounds and refuses to diet be given a heart transplant?Should a brain-damaged patient with a functional IQ of 35 receive an artificial kidney?Should someone spending life in prisonfor homicide qualify for a life-saving liver transplant?Should a person with no discernible cerebral cortex (like Terri Schiavo) be kept alive indefinitely via feeding tube if there is no living will?Should an infant with a malformed brain and no function above the brainstem be kept alive on ventilator and feeding tube if that is the parents’ wish?Should the public purse pay for a cancer drug that will prolong life by two months at a cost of $93,000?Should a micro-preemie weighing less than one pound be kept alive at enormous cost if the statistically likely outcome is cerebral palsy and blindness?Hard questions indeed. Terrible moral conundrums. (I’m posing the questions but I don’t know the answers.) So do we continue to avoid these questions because they’re difficult and divisive? Can we ever reach consensus… and if not, what then?

  25. DC Petterson says:

    Michael:It’s all anecdotal, of course, but medicine is something so deeply personal that everything is anecdotal.All worthy considerations. My central point was that each of these considerations must be taken in context. You point this out too, saying that lifespan (and even more so, quality of life) is more a function of early care (including childhood, and even pre-natal) than it is of late care. The whole approach must be considered as the whole it is.I merely wanted to stress that isolating a single factor, as Jeff did, gives less than the whole story. There seems to be an unfortunate tendency to take a single phrase or element out of context, and condemn an entire system based on that one factor — without taking into account the totality of the system.We’ve certainly seen that often in the U.S. debates about health care reform. I think most of us would agree that it’s counterproductive to criticize an entire approach due to one element taken out of context, and, usually, misrepresented.

  26. Eusebio Dunkle says:

    Excellent post. I use this to emerge from the shadow as the petulant progressive opponent of BHO. I’m young. I’m in great shape. I eat my vegetables. I exercise 130 min about 280 d/y I have an optimistic, immodest outlook.I also have a sick health insurance plan. I don’t even know my annual premium, maybe 60-80$?. Maintenance is free and everything thereafter costs a $10 copay. I still haven’t had a physical or seen a dentist in 3+ yr. I even put off my $10 vasectomy for nearly a year now because I’m lazy. I’ll think about health care when I’m 40 and consider additional testing when I’m 50.I want death panels. I want a clear distinction between those who attempt to prevent chronic conditions and those who embrace them via their life-style. For catastrophic external events I should enroll in a semi-transparent program like my auto/home insurance. For any other medical insurance program, my premium (or out of pocket cash expense) should reflect my healthy position on the long tail of the normal curve. It should have nothing to do with my employment.It seems perfectly reasonable to me, but this perspective is unreasonable to my opponents in most debates on the issue. On the other had, they remain oblivious to their own hypocrisy and many of the glaring contradictions discussed in previous comments.

  27. filistro says:

    Eusebio! Welcome, I’ve wondered if you would ever turn up 🙂I use this to emerge from the shadow as the petulant progressive opponent of BHO.You have company here. Our plan is to ply you all with cookies and tequila and try to win you back. I’m young. I’m in great shape. I eat my vegetables. I exercise 130 min about 280 d/y I have an optimistic, immodest outlook.Hey, me too!!! Well, except for that “young” part. (Nowadays I prefer “youngish”… )Again, welcome. Good to see you. You always make me laugh, and I like that 🙂

  28. Michael Weiss says:

    @Eusebio Dunkle,Nice of you to join us. How do you think things should work with respect to having multiple sources of payment for medical services? I’d expect this to cause fragmented medical services (i.e., different coverage resulting in different doctors in scope on different plans).I have a second question for you as well. You describe how you would address each of the fragments of medical services individually. How would you address the grey areas where they overlap?

  29. mclever says:

    Esubio, what if tomorrow you were diagnosed with an internal crisis condition, such as brain aneurysms or leukemia? These would be no fault of your own healthy maintenance habits, and they wouldn’t be the result of an “external” crisis either. Under the scenario you described, this wouldn’t be covered.So, if this were to occur, should your monthly premiums suddenly skyrocket to cover the maintenance costs of keeping your new-found condition under control? What if you already knew that you had the genetic propensity to develop one of these conditions? Should your premiums be 10X higher to compensate?Young people like to think such things can’t happen to us, but thousands find out every day how wrong they were.

  30. mclever says:

    Eusebio Dunkle, I apologize for misspelling your name in my previous post. I’d blame it on my dyslexia or on typing too fast, but such excuses don’t make it right. I promise to pay better attention to the proper spelling going forward.

  31. filistro says:

    Actually Michael’s title says it all… and much of the problem (as is often the case) begins with semantics. “Health insurance” and “health care” need to be uncoupled and dealt with as the separate entities they really are. The former is a safeguard against the unforeseen… the latter is (or should be) a basic human right in a developed nation.

  32. Jeff says:

    Michael Weiss wrote: How do you think things should work with respect to having multiple sources of payment for medical services? I’d expect this to cause fragmented medical services (i.e., different coverage resulting in different doctors in scope on different plans).===========Interesting question. Do HC plans try to do too much? Are doctors so expensive because they have to spend so much time in school? A nurse practicioner can do 90% – 95% of what an MD does, but it’s the equivalent of a masters, not a PhD +++. I don’t know how to solve the HC problem and I suspect that nobody has “THE ANSWER.” But that to me means that we’re either not framing the question correctly, or we’re not attacking the problem correctly. It’s been proven time and again that the collective wisdom of crowds is much greater than of “experts.” My main criticism of Obamacare is that it’s a so-called “solution” from experts (plus a heavy dose of politics). It’s not my recipe for good results, and it will make it much harder to try alternative solutions.My off-the-cuff solution(s):1. End employer-based HC. Easily done through changing the tax code. Replace with individual HSA/high deductible plans. Promote universal coverage with a tax credit for HSA’s to make them affordable. As you point out, HC is one of the very few economic activities where the recipient doesn’t do the purchasing. 2. Require HC providers to post prices for treatments, not activities. Nobody could comparison-shop if every part in a car was individually priced, but hospitals spend fortunes billing each aspirin and bandaid.3. Encourage fragmentation and specialization. There’s no good reason why an OB/GYN needs to know how to set a bone. Annual checkups and a routine lab battery shouldn’t be horrifically expensive if they’re not also combined with surgery.4. Take steps now to reduce costs in the system. Nobody knows the true cost of malpractice insurance and defensive medicine. It may be 2% of cost, or it may be 20%. Whatever it is, it’s mostly unnecessary.The goal should be to encourage a market-based, consumer-driven system. I believe that will spur innovation and lower costs. The classic example conservatives use is Lasik eye surgery, where costs keep on dropping and quality improving. It’s also the only medical sphere where there are no government or insurance reimbursements.I think the emergency room problem is overstated. Objectively, there are arguments to be made that “emergency” room service should be cheap. Outside of trauma centers, they rarely perform major surgery — it’s mostly patch them up and ship them out, and is probably a prime example of how the reimbursement system distorts costs.Finally, accept that there will always be “rationing.” The President, with 24/7 attending physicians, will always have better coverage. HOW to ration is another question, which I’ll handle separately since I’m running out of characters.

  33. Mr. Universe says:

    @ filiMr U… I’ve always been interested in the Oregon model for health care reform… it just seems so sensible.How is it viewed in-state?I confess I remain purposefully ignorant of such things. I got turned off by the whole mess in the nineties. I can say that I’ve heard good things about the Oregon Health System and my Senator Wyden has been very involved in the national reform process. It’s also one of the reasons I hope Governor Kitzhaber (an MD) gets re-elected.

  34. Jeff says:

    Rationing (continued).I previously said that there always will be rationing. Canada rations healthcare, and rich and powerful Canadians can go across the border. Even if we decided to devote 25% or 35% of GDP to HC, the rich and powerful will get the best doctors. To say something that will be grossly unpopular, if we’re concerned about cost, rationing needs to be done on some sort of economic basis. We ration housing, cars, and food on that basis, but the economic separator is quality, not access. Why not a system where the low-end plans provide access to nurses, where hospital wards have 30 beds instead semi-private rooms, and generic medicines instead of the latest and greatest? The difference in outcomes won’t be all that great, and if lower-income people want to chose to pay more for an upgraded medical policy, they can make the appropriate tradeoffs in the rest of their lives. When we take vacations, few of us can afford to stay in 5-star hotels, fly first class, and eat at gourmet restaurants, but the majority of people COULD do so — at least occasionally — if that was their goal in life. It might mean driving an old car and living in a cheap rental, but the ability to make trade-offs exists. Why shouldn’t that also be the case with medical care? We should make medical care available to everybody — and did so before Obama was even elected. Our problem wasn’t and isn’t availability, but cost. The political argument is whether a government designed system (which we have with Medicare and Medicaid) is going to give you better results (in terms of cost and quality both) than a market-based system (which we haven’t had since the 1940’s). If you want to lower cost you need to send the appropriate economic signals and let the marketplace figure it out. You can still provide basic levels of service to those who can’t afford it, just as we provide basic housing and food. But we all can’t have premium medical care with all the bells and whistles, any more than we can all afford to drive a Mercedes.

  35. Michael Weiss says:

    Jeff,I agree that employer-based health care is an anachronism, and I’d like to see it eliminated. We’d need some form of transition, though, and some mechanism by which to ensure that there isn’t a pre-existing condition gap.But I don’t understand why you want to replace it with “individual HSA/high deductible plans.” It’s not as if there’s only one type of auto or homeowner’s insurance. Why be so limiting in this space?The notion of requiring “HC providers to post prices for treatments” is an intriguing one, but your analogy of car repair doesn’t work. Many, if not most, car repair shops do charge time & materials, which is how medical services typically charge today.I think the fragmentation and specialization is happening, regardless of what happens in the insurance space. But there’s a point of diminishing returns on that model. Biology doesn’t work in quite the same way as mechanical devices do. There are many more complex feedback loops, and lacking knowledge in the overall system is potentially far more dangerous.I beg to differ regarding the cost of malpractice insurance. That number is crystal clear. As for defensive medicine, the economic factors driving it appear to be much stronger via the channel I outlined than via any liability. But you make a very specific assertion here: “Whatever it is, it’s mostly unnecessary.” How do you know this?To your final points, I agree that a market-based, consumer-driven system would be an improvement over what we have today, and rationing will be required regardless of the path we choose. However, do you want to have a minimum bar below which we will not allow care to fall? If so, how would you administer this?

  36. Eusebio Dunkle says:

    @filistro,Thank you for the welcome. IMHO, BHO is a war criminal =)@Michael Weiss,Hard questions I cannot answer. I think disability should cover a lot of end of life stuff (say government helps you die if you are within 1stdev of life expectancy).Ugh lost my post. My answers were poor. Your questions too difficult. Generally, I’m willing to sacrifice efficiency and fairness for simplicity. I endorse standardized medicine, transparent costs, and wages and costs that depend on outcomes.@mclever,”if tomorrow you were diagnosed with an internal crisis condition, such as brain aneurysms or leukemia?”Correct. Living entails risk. I accept that risk.”should your monthly premiums suddenly skyrocket to cover the maintenance costs of keeping your new-found condition under control?” Probably. “What if you already knew that you had the genetic propensity to develop one of these conditions? Should your premiums be 10X higher to compensate?”I’ll leave the cost premium to actuaries.”Young people like to think such things can’t happen to us, but thousands find out every day how wrong they were.”They can happen. They are statistically unlikely. These risks are orders of magnitude smaller than engaging automobile traffic on my bike/car, which I do every day.

  37. filistro says:

    @Eusebio: IMHO, BHO is a war criminal Oh dear. We’re going to need more cookies.(AND a bigger bottle 😉

  38. dr_funguy says:

    What do you mean: “Canada rations healthcare”?

  39. filistro says:

    @Doc.. “What do you mean: Canada rations healthcare”?Sigh… don’t even try, Doc. The Republicans have spread these fallacies so widely and effectively that everybody in the US believes them… even my many American friends on the left.They all think we are dying while waiting for cancer treatement, and have one MRI per province, and get turned away from ER’s with life-theratening conditions, and wait 5 years for hip replacements, and cross the border in droves to seek treatment in America. You can’t convince them otherwise. It’s hopeless.

  40. Monotreme says:

    Eusebio wrote:They [catastrophic pre-existing conditions, such as a brain aneurysm] can happen. They are statistically unlikely. These risks are orders of magnitude smaller than engaging automobile traffic on my bike/car, which I do every day.Au contraire, mon frêre. The incidence of cerebral aneurysms is estimated at 1-6% of the population, or about 1 million Americans, taking the middle of that range. When these aneursyms burst, death almost always occurs instantaneously. I wouldn’t describe 1-6% as “statistically unlikely”, and they’re definitely NOT “orders of magnitude” smaller than morbidity and mortality from automobile accidents.

  41. Michael Weiss says:

    Monotreme, you just illustrated what I mentioned in the article, that humans are terrible at guessing relative risk.

  42. I will read time to time that

  43. shiloh says:

    “We” have our first spam, if you don’t count Undeniable/shilohbuster.carry on

  44. Eusebio Dunkle says:

    @Mono, MichaelI disagree. <3.3% is statistically unlikely and I am comfortable with those odds.I’m also pretty confident that 1/100 let alone 1/20 of 25-34yr olds are not dying of brain aneurysm. The risk factors look like old age and poor life-style…In any event, ~60% + of deaths for males 20-40 are accidents, even at 5% rate of brain aneurysm that is an order of magnitude+ difference.http://www.benbest.com/lifeext/causes.html

  45. Michael Weiss says:

    Eusebio Dunkle, you’re not disagreeing with what Mono or I were saying. In fact, you’re proving my point yet again.Mono pointed out that the likelihood of dying of an aneurism is not orders of magnitude less than dying in an automobile accident.You then mixed two different statistics and compared them as if they were the same. The 60% number is the percentage of deaths. The 5% number is the percentage of people.This is why so many people say that statistics are used to “prove lies.” If you don’t understand the statistics, you’ll draw very incorrect conclusions.

  46. Michael Weiss says:

    Oh, one more thing. I know it’s anecdotal, but it’s worth considering.I personally know a man who is now in his late 20s. He has always been fit, and has led a healthy lifestyle. A few years ago, he nearly died of a burst aneurism in his brain. As it was, he was in a coma for weeks and has been undergoing rehabilitation ever since.Incidentally, he had only high-deductible, high copay health insurance, in large part because he shared Eusebio Dunkle’s attitude about the need for it.It bankrupted him, and drained most of his dad’s retirement savings.Just some food for thought.

  47. mclever says:

    Michael, do we know the same friend?I have an almost identical anecdote… In fact, I have several anecdotal stories about friends and family who’ve been hit by unexpected medical problems (not “accidents”, but surprise diagnoses for chronic and/or debilitating conditions) that have resulted in financial difficulty *despite* having “insurance” coverage. Some people don’t think they are at risk of medical complications because of their healthy lifestyles. WRONG! These things can happen, and with sufficient frequency that it is beneficial to society as a whole to ensure that the cost is well-distributed across the general population. Else, when these people are on the verge of bankruptcy, we’ll hear them complaining, “Why doesn’t the government do something to help me?”

  48. Monotreme says:

    I think a healthy dose of experience with life, and particularly life inside a health care environment, will cure most of the problems noted above.In my previous job, it was part of my responsibility to attend something called “Neurology/Neurosurgery Grand Rounds”. Every week, I was “treated” to an interesting case from either the Neurology or Neurosurgery service at the large teaching hospital I worked at. For the first few years, my reaction (as a healthy man in his early 30s) was to say, “that couldn’t happen to me because…”Later, that turned to a much more reasonable “there but for the Grace of God go I…” which is the space I occupy today.The discussion above also illustrates another point that I’ve been trying to make and I think Michael and others would agree with.The brainstem decides, and the cortex supplies the reasons.Or, put in more conventional psychological terms, the subconscious mind does a calculation based on emotion and genetic predispositions, and then convinces the conscious brain, the big crinkly part, of the “rightness” of its conclusions.This is what we were calling “epistemic closure” in an earlier thread, and we’re all subject to it. In fact, the only way to avoid it is to actively fight it.”That would never happen to me” is epistemic closure.”That could happen to me, but it’s not likely, which is good because it would sure suck if it did” is closer to reality for most of us.

  49. mclever says:

    Absolutely, Monotreme! 🙂

  50. Michael Weiss says:

    I don’t usually make a practice of such comments, but…I completely agree with Mono on that comment. Every single word.

  51. filistro says:

    @Mono… The brainstem decides, and the cortex supplies the reasonsThat’s true in so much of life (including politics.)We all like to think we’re balanced, reasoned and logical thinkers.But in fact, so many of our most fervently-held opinions aren’t actually rational… they’re just rationalized.

  52. DC Petterson says:

    And let’s take a step beyond Monotreme’s excellent points.A libertarian might say, “Sucks for you. You got an illness, or cancer, or got hit by a bus, through no fault of your own. And you hadn’t prepared for it — no insurance really, just a crappy HSA with a high deductible”– note” ALL “insurance” policies with HSA’s and high deductibles are crappy.) –“so, that’s YOUR problem. Why should I pay for your shortsightedness? Sucks to be you.”The problem is that we all pay. If you get medical treatment, but can’t pay for it, the hospitals and insurance companies have to charge me more. And if you don’t get medical treatment, then you don’t live as productive a life. You don’t contribute as much to society, and don’t pay as much in taxes, and my burden goes up.Ayn Rand’s idiotic fantasy that we are all unconnected islands is a piece of drivel that needs to die. Each of us affects everyone else. To pretend that someone else’s suffering — or even someone else’s bad decisions — will not impact me is nothing less than willful blindness.I wonder if the Teapers really are willing to die or impoverish for their convictions. The answer, of course, is no. How many of them refuse to go on Medicare? How many of them draw on Social Security? How many drive on the public roadways, or use the public airwaves, or allow their city’s garbage collectors to take their trash? How many eat federally-inspected foods? or enjoy the protection of our national military?Their afraid they may be helping someone else directly. Yet most of them do have some insurance (even crappy HSA’s) — and hope they never have to use it. Unless they have a claim against the insurance companies every single year, they’re already paying for someone else. I dare any Teaper to drop his or her insurance completely. Live honestly, or admit your dishonesty.

  53. shiloh says:

    @We all like to think we’re balanced, reasoned and logical thinkers.~~~~~And unlike myself 😉 so few of us are.>ok, some of you folk are a tad more intelligent/articulate than me, but I’m here to learn and process!Which again begs the eternal 🙂 question:Why do some liberals switch to being conservatives and vice/versa.hmm, environment, personal experiences, rationality, education er lack thereof. 😉What a terrible thing to have lost one’s mind. Or not to have a mind at all. How true that is. ~ Dan Quayle>When you find yourself in the majority, it’s time to pause and reflect! ~ Mark Twain

  54. filistro says:

    I dare any Teaper to drop his or her insurance completely. Live honestly, or admit your dishonesty.You know, I’ve never really considered that… but insurance is actually the ultimate in collective, co-operative behavior, isn’t it? A group of people who share a similar risk join together co-operatively to share the resulting cost.What a bunch of commie pinkos. I bet there’d be no insurance salesmen in Galt’s Gulch!

  55. filistro says:

    @shiloh.. Why do some liberals switch to being conservatives and vice/versa.Now that’s the kind of discussion I find especially fascinating. In fact I think I’ll steal the idea from shiloh and post it in Free Forum Friday, and see what everybody in here has to say about his/her own political evolution.

  56. filistro says:

    ..and this seems strangely apropos to any health insurance discussion:Jon Stewart confronts House Minority Whip Eric Cantor (R-VA): It’s “fallacy that limited government is the principled stand of conservatives. It’s only limited to the shit they want to do.”

  57. mclever says:

    Shiloh, I migrated from conservative to liberal after a series of life experiences opened my eyes to some of my prior blind spots. While still blinking with uncertainty, I moved to Texas where I was confronted with an absolutist form of conservatism that I had not previously encountered. There, no one questioned their conservative convictions. Call me contrarian, but when I’m confronted with too much absolutism, I have a tendency to play Devil’s Advocate and look for flaws or counterarguments. Someone says, “The sky is blue,” and I immediately think, “Except at night, or at sunset, or when it’s gray or cloudy.” In any case, more than once, after asking questions that challenged the conservative gospel, I was cursed and labeled as a “@#&% Liberal!” That served as the final push to turn me leftward. Having never considered myself liberal, I paused to take stock of what my actual political inclinations were. To my surprise, I discovered that I was much more liberal than I’d realized.The constant analysis of my underlying assumptions and resulting political conclusions is now an ongoing process…:-)

  58. Michael Weiss says:

    DC says,”I dare any Teaper to drop his or her insurance completely. Live honestly, or admit your dishonesty.”Whoa there, nelly. The issue isn’t so much about the collective nature of insurance, but rather forced participation. At least among those in the libertarian wing of the Tea Party.From their perspective, as long as people buy insurance by choice, there’s nothing wrong with it. Once you’re forced into the plan (such as via taxation), then it’s no longer a voluntary transaction.So it’s not about participating in a collective. It’s about the ability to choose.

  59. DC Petterson says:

    @MichaelThe issue isn’t so much about the collective nature of insurance, but rather forced participation. At least among those in the libertarian wing of the Tea Party.I agree this may be true for actual Libertarians. If the issue was about choice vs. compulsion, I’d expect an Libertarian to come down on the side of choice. However, when proposals were floated to expand the choices available — as in insurance exchanges with a public option — a big part of the Teaper opposition came from the simple presence of a government option. They say they’re fine with the idea of selling insurance across state lines — but would oppose adding a national health plan into that mix of available cross-state plans, even if it was entirely voluntary.So: I agree that a pure Libertarian would simply be concerned with the issue of choice — and thus would also support things like same-sex marriage, legal abortion, decriminalization of drugs and prostitution. My point is more that very few Teapers are actually Libertarian. Certainly, the positions taken by the “Tea Party candidates” and the majority of TP commentators and sign-wavers do not seem consistent with Libertarian values.

  60. shiloh says:

    @Shiloh, I migrated from conservative to liberal~~~~~Again, have always marched to the beat of my own drummer ~ shocking! ;)Have to laugh at another political forum was accused of being part of a liberal clique which actually had there own private liberal blog which I was not aware. Have always considered myself an independent contractor as I too used to enjoy playin’ the devil’s advocate. Although, as expected, did agree w/my progressive brethren on most topics.Long story short ~ Didn’t like the Vietnam War, didn’t like Nixon er first impressions. My family was not political. Politics was never discussed. But, but, but was raised a Catholic and learned the Bible. As you say, how can Evangelicals continue to vote conservative, basically re: (2) issues, abortion and Gays.hmm, the phrase limited world view comes to mind, especially since these god fearing Evangelicals supposedly know the Bible a lot better than me, eh. A total disconnect as you are your brother’s keeper. We’re in this together. Your either part of the solution or part of the problem.Enough clichés.Have always been an independent liberal. Joined the USN and the military tends to make everyone more nationalistic which it also did w/me but had absolutely no effect on my politics. Reagan was my C-in-C for (8) years and I didn’t vote for him, no biggie.Didn’t start talkin’ politics until 2003. It’s amazing what you waste your time on as you get older ;). Obama was the first and only time I donated money to a political campaign.btw, my dad’s only time voting was the 1992 national election. He passed away in ’93. Got him a registration form, he filled it out. Got him an absentee ballot form and he filled it out. He voted and we have no idea who he voted for, although James “Bo” Gritz was on the OH ballot for president in ’92 and my dad seemed “infatuated” w/a politician named Bo. :)My oldest nephew is a die hard liberal as he voted for Kucinich in the NY presidential primary. His cousin’s wife in FL is 100% convinced Obama is the anti-christ!and so it goes …

  61. DC Petterson says:

    100% convinced Obama is the anti-christ!The funnies thing about that is, Revelations insists that no one will recognize who the anti-christ is until all the excitement is long over. Which means that anyone who honestly and sincerely believes that the prophecies of the Bible are literally and completely true, would not ever think the anti-christ could be identified.Just sayin.

  62. filistro says:

    Which means that anyone who honestly and sincerely believes that the prophecies of the Bible are literally and completely true, would not ever think the anti-christ could be identified.Yes, but you could still pick a favorite, do well on long shot and make some easy cash (an important consideration if you happen not to do as well on the whole Rapture thing…)

  63. shiloh says:

    @DCJust sayin.~~~~~Indeed 😉 but as many names as Obama was called during the 2008 campaign ~ from the anti-christ to sarcastically the second comin’, literal translations can get lost in the The Rapture er shuffle …

  64. shiloh says:

    lol Fili as I didn’t see your Rapture post until after posting mine.Surely a sign of the Apocalypse …

  65. Eusebio Dunkle says:

    @Michael Weiss,Ugh, I knew I would catch grief for my laziness, but I thought you might also recognize “error” was conservative =). Monotreme says brain aneurysms imply certain death. The Mayo clinic says 50%. People aged 25-34 die at a rate of ~1.0%. This shows us that young people are not dying of brain aneurysms at anywhere near Monotreme’s 0.5% – 2.8% (assuming 50% mortality), unless 50% – 280% of 25-34 deaths are of aneurysms, which I hope you agree is not true.http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf pg 32.Since cerebral aneurysm is not one of the 113 main leading causes of death by the CDC I used ‘Cerebrovascular diseases.’ If I use http://en.wikipedia.org/wiki/Cerebrovascular_diseasethen cerebral aneurysm is max 10% of cerebrovascular disease. This gives us a range from 10% to 100% of these deaths.So 50.5 to 505 deaths out of 42572 total deaths = 0.12% – 1.2% of deaths.Accidental deaths are 35.2% Thus, I am 29.8 – 298 times as likely to accidentally die than get a brain aneurysm. Another way to look at it is that I have a 1/8333 – 1/83333 chance of dying of brain aneurysm each year. I will stand by my orders of magnitude. I will concede this is way higher than I expected, but still insignificant.

  66. mclever says:

    Coming from a long line of conservative evangelical born-again believers who fervently discussed politics and religion at the family dinner table, my understanding is that the scriptural admonishment is to always be prepared and always be looking for signs of the end times [and the return of Christ]. Of course, the scriptures go on to say that no one will recognize what’s really happening, but Jesus’s admonishment to always be watchful kind of encourages rampant speculation amongst the faithful, er, hopeful.:-)

  67. Jeff says:

    michael says: But I don’t understand why you want to replace it with “individual HSA/high deductible plans.” It’s not as if there’s only one type of auto or homeowner’s insurance. No argument. There’s room for different types of plans. If you have enough money for a “cover whatever” plan that means you never have to shop, so be it.===========You say “The notion of requiring “HC providers to post prices for treatments” is an intriguing one, but your analogy of car repair doesn’t work. Many, if not most, car repair shops do charge time & materials, which is how medical services typically charge today.”Yes, they do. But at least here in California they also give you a written estimate and can’t exceed it unless the scope of work expands. You say: I beg to differ regarding the cost of malpractice insurance. That number is crystal clear. As for defensive medicine, the economic factors driving it appear to be much stronger via the channel I outlined than via any liability. But you make a very specific assertion here: “Whatever it is, it’s mostly unnecessary.” How do you know this?I agree that the cost of malpractice insurance PREMIUMS is crystal clear, but I include defensive medicine as part of the cost, and that number is very unclear. I have seen estimates ranging from 2% to 20% or more and, since getting a better number would require mind-reading, to me it’s unknown.My comment as to the cost being “mostly unnecessary” has to do with the overhead costs. A plantiff’s attorney typically takes 30-40% off the top when there’s a settlement. Additional time and money is spent by the defense. The doctor loses a lot of billable hours, even in a settlement, let alone a trial. Then add some “defensive medicine cost to the equation. Perhaps I overstate, but if you compare to no-fault workers compensation, I think that “more than half” is a fair statement. You say: However, do you want to have a minimum bar below which we will not allow care to fall? If so, how would you administer this?We have a minimum bar right now, via the emergency room, supplemented by Medicare and Medicaid. At least for now, I would keep that basic system intact.My opinion (not stating a fact) is that centralized, top down systems don’t do a good job of combining cost control or delivery of a good product, while decentralized systems operating with strong economic incentives are far more likely to give a bigger bang for the buck. I agree that universal coverage is a good goal, and that there are many laudable features about the HC bill. I think that on balance it is going to be worse than the existing mishmash, and far worse than a market-driven alternative. And yes, I think you can use market and tax incentives to have essentially universal coverage, and that some regulation will be required to make the system work.

  68. Jeff says:

    DC Petterson said:Insurance companies tend to be inefficient, much less efficient thay, say, Medicare or the VA. Traditionally, only about 70% – 80% of insurance premiums go to pay medical costs (the new HCR bill now requires this number to be 85%). The rest goes to salaries, stock dividends, and various other corporate waste and inefficiencies. In contrast, the Medicare overhead is ony about 2%. It isn’t the profits that cause these inefficiencies per se. It is the fact that insurance companies are profit-driven rather designed for the benefit of customers.=========I don’t argue with your numbers, but with your conclusions. Medicare and Medicaid are closed systems, with the compliance costs at the other end. Much of the overhead in hospitals is devoted to doing the documentation they require. Insurance companies work to deny claims because the user isn’t their customer. Companies sign up with the cheapest provider, not the one with the best balance of price and quality. As for the new 85% requirement — this is a typical case of dumb regulation based on insufficient knowledge of economics. Suppose the “average customer” pays $10,000 per year for family coverage and it costs $3000 per year for admin and overhead. “Profit” and “huge corporate salaries” don’t account for all that much — the big bucks are in claims processing, etc, and we can assume that the insurance companies do their best to minimize those costs. What is the likely outcome? If the desired/necessary target is a $3000 gross contribution on a $10,000 policy, and the government is saying $1500 is all you get, then your new premium is going to be $20,000 and there will be no restraint on the size of payments. OR, because there’s always an alternative, the insurance company just stops writing insurance.I’m amazed at the incredible stupidity of politicians who think that they can make price controls work. They never work, and they usually make matters worse.

  69. Jeff says:

    Michael:You say: “elimination of all malpractice judgments (which I can’t imagine anyone endorsing) would reduce our medical expenses by only 2%.=========Do you really mean “judgments” did you intend to say “costs.” Judgments are a relatively low proportion of costs, since most cases are settled out of court. I’ve never been involved in a malpractice suit, but the legal principles are similar in wrongful termination and discrimination cases. I went through one a few years ago and the insurance company said:1. You have one of the strongest, best-documented cases we’ve ever seen, and should easily win in court.2. However, if you lose, you could easily have to pay $1 or $2 million, plus the other side’s attorney’s costs and fees (which will be generously stated). We don’t get attorney’s fees if we lose. Worst case scenario is a $3 million cost. Appeals by either party just make it worse. 3. It’s impossible to say what a jury will do in any given case, but a good rule of thumb is that there’s at least a 10% chance of losing. So, guess what happened? If you guessed a $250,000 sealed settlement, you’re correct. And the plantiff’s attorney walked away with a cool 40%, or $100,000. And the case was settled in mediation, which means the plantiff’s side only had to put in about 2 days worth of work.The obscene court decisions you hear about are only a small fraction of the cases that go to court, but the cases that go to court are only a tiny fraction of the cases that are settled out of court. Malpractice tort reform isn’t about the 2% of medical costs attributable to court judgments, they’re about all the cases settled out of court as well.

  70. Michael Weiss says:

    Jeff:You include defensive medicine as a part of the cost of malpractice liability and lawsuits. However, I pointed out why the defensive medicine we see today would remain even if malpractice liability were eliminated altogether. My use of the word “judgement” was ill-chosen, though, as you noted.The 2% is the amount paid for everything coming out of malpractice, according to the information I read. It could be wrong, and I welcome you to provide evidence to the contrary.

  71. Jeff says:

    Michael,Concerning the cost of malpractice insurance — I said that I had seen numbers ranging from 2% to 20%. Here’s an article saying it’s 10%, excluding excessive defensive medicine. It’s byDiana Furchtgott-Roth, former chief economist at the U.S. Department of Labor, is a senior fellow at the Hudson Institute (admittedly a conservative group, but generally considered reputable).http://blogs.reuters.com/great-debate/2009/08/06/reduce-the-high-cost-of-medical-malpractice/This paragraph is especially telling: “Congress could use health reform legislation to give incentives to states to reduce the costs that lawyers’ fees place on the health system, while still protecting patients. Fear of lawsuits can diminish patient safety, as hospitals and physicians become wary of keeping records of errors—records that could result in safer procedures being put in place.”Two points: First, we have safe airplanes because there’s a culture of trying to honestly find out what caused a problem. The HC system penalizes people who try to identify problems. God only knows how much that costs in terms of inefficiency and failure to correct bad practices.The second point I’d make is that there was a lot of good stuff in the HC bill, but a lot of bad stuff (from the conservative standpoint) as well. Would it have hurt the Democrats (other than pissing off one of their largest donor pools) or the goal of quality, affordable HC to have put meaningful tort reform? Given the amount of money spent on HC, whether the excessive malpractice cost is 10% or or 20% or 2%, it’s meaningful money.

  72. shrinkers says:

    @JeffThe HC system penalizes people who try to identify problems.Have you any numbers to back this up?Would it have hurt the Democrats … or the goal of quality, affordable HC to have put meaningful tort reform?Yes, if what you mean by “meaningful tort reform” is putting a limit on monetary awards for damages. The only meaningful penalties are ones that hurt. Otherwise, it’s merely a cost of doing business.The number of malpractice suits that result in large awards is vanishingly small. This “meaningful tort reform” meme is just another bit of deflection away from the real issues.

  73. shortchain says:

    Jeff,Some random talking head giving a number with absolutely no citation for where the data came from is not evidence. The 2 percent figure for malpractice costs comes from the Congressional Budget Office.The 10 percent figure apparently comes from an older (2003) study by the Department of Health and Human Services that gave as 2 percent the direct cost of malpractice and an additional 5-9 percent due to “defensive medicine”.Reflect on the difficulty, as Michael commented above, on establishing that the sole purpose of defensive medicine is to avoid malpractice (what, your doctor doesn’t care whether you live or die, just whether your heirs sue?).Now, if there were some national standards for what constitutes appropriate care for given symptoms, then “defensive medicine” could be identified by seeing what was done in excess of that. Lacking that, “defensive medicine” is a very slippery quantity to measure.As in, was it “defensive medicine” that the doctor ordered a chest X-ray, or was the happy coincidence that the doctor’s office had a very expensive X-ray machine which would otherwise be nothing but a drain on resources? If you ask the doctor, what will he/she say? “defensive medicine”!So I’m afraid I have difficulty accepting these “defensive medicine” cost claims.

  74. mclever says:

    Jeff,I would strongly dispute your “minimum bar” with emergency rooms and medicare/medicaid, because way, way, WAY too many people are not and cannot be served by those alone. Witness that the number one cause of bankruptcy is medical costs. If the “minimum” safety net were adequate, that would not be the case. Or, if you want to go anecdotal, people like me who make too much money to qualify for Medicaid, are too young for Medicare, and have a “pre-existing condition” that makes (made?) it impossible for us to purchase medical coverage on their own. That’s right, impossible. A little over three years ago, I got a surprise letter from BCBS saying my plan was being discontinued, so I needed to reapply. I’m a healthy, young adult, so I thought it’d be no problem. To my shock, BCBS rejected my application for a similar plan. I then applied to over 30 different plans in every company that offered coverage in my state, and was rejected by all of them. I enlisted an agent to help me, and he also came up with blanks. I couldn’t buy health insurance. My PCP was shocked, because I’m healthy according to her! Thankfully, my spouse found a new job that offers spousal coverage, but what would I do if that hadn’t worked out? Should I be left to rely on the emergency room? Great, then I’d be on the hook for the hundreds of thousands of dollars if something really bad happened. No thank you. I’d like to keep my retirement accounts that I’ve worked so hard to establish.Basically, my medical coverage is hostage to my spouse’s employment. While better than nothing, this certainly isn’t ideal. What if my spouse gets laid off???Of course, the latest healthcare bill should fix the “pre-existing condition” problem, but I haven’t tested it yet. It remains to be seen if any medical plan will be affordable. Nevertheless, I would be very, very upset of the Republican goal of repealing all of “Obamacare” went through, because then I’d be right back where I was before with absolutely no way of purchasing healthcare coverage on my own. Oh, BTW, what was my terrible, horrible pre-existing condition? Occasional migraines, ADD, or acne from five years ago. Take your pick. The various companies cited one or more of these in their rejection letters. I shudder to think what it’d be like if I had a serious ongoing condition such as Type-I Diabetes.

  75. shrinkers says:

    @JeffWhat is the likely outcome? If the desired/necessary target is a $3000 gross contribution on a $10,000 policy, and the government is saying $1500 is all you get, then your new premium is going to be $20,000 and there will be no restraint on the size of payments.No, because there also are going to be restrictions on the amount insurance companies can raise their rates.It’s common to criticize government for being inefficient. This is an instance in which government is clearly more efficient than private corporations. The regulation is merely to require corporations to be slightly less stunningly inefficient than they currently are, not that they even begin to approach the efficiency of Medicare or the VA.OR, because there’s always an alternative, the insurance company just stops writing insurance.Oh, if only. Get rid of the leeches entirely. Force us into Medicare For Everyone. One can only hope.

  76. Michael Weiss says:

    Jeff, I, too, have seen malpractice numbers ranging from 2% to 20%. When they cover only the cost of the insurance, it’s always 2%.The problem with the remaining 18% there is the assumption that, absent liability, those tests would not be run. However, as the system is currently set up, neither the doctor nor the patient has any incentive to not run the tests. So it’s not credible to claim that it’s because of liability insurance.Furthermore, I should remind you that, in order to then reduce the costs of health insurance by 2% via tort reform aimed to reduce malpractice insurance costs, we’d be eliminating altogether any liability. Surely you’re not proposing that doctors be immune to liability, are you?Even if we were to assume that 50% of liability insurance payouts are frivolous (and that’s absurdly high), we’d save a whopping 1%. Focusing on tort reform is a rounding error and a distraction. It’s not meaningful money.To your other point, however, we are in agreement. Root cause analysis is important in medicine, and the health care system in the US today hides way too much. The AMA works to protect the worst doctors from scrutiny, and that works counter to the needs of the patients.

  77. Bart DePalma says:

    Michael:I agree with much of your analysis, if not your conclusions.Health insurance must be limited to catastrophic conditions because, as you observed, these are the only conditions which the insurance model is competent to address. Covering everyday medical expenses and having someone else pay for most of it causes overuse of medicine and the inflation we are seeing in health insurance premiums.The hybrid of health insurance and health savings accounts is the best method to date I have seen to address medical overuse and health insurance inflation.The other major problem are free riders. Health (and any other kind of) insurance only works if everyone contributes to the risk pool. Allowing the uninsured to guaranteed free treatment in medicaid and emergency rooms encourages free riders. The Obamacare requirement that insurers cover preexisting conditions allows the uninsured to hop on and off insurance only during times of sickness. This puts the free rider problem on steroids and will bankrupt the insurance system as it is doing under Romneycare in MA.This libertarian has been forced to conclude that the only way to deal with free riders without denying care to the foolish uninsured is to have the government make health insurance an public good. However, governments have shown themselves particularly inept at running health insurance as the massive fraud rates in the US Medicare and Medicaid as well as the rationing imposed by most other nations demonstrate.Thus, I would suggest that the government impose a medicare like tax and then use the revenues to pay for hybrid health insurance/HSA plans with the added encouragement of allowing the recipient to keep any unspent money in their HSA after each year. This plan has the benefits of allowing each stakeholder do what it does best – government taxing, insurer administration and individual self rationing.

  78. Michael Weiss says:

    Bart,A few flaws in your otherwise good critique:First, you said: “Covering everyday medical expenses and having someone else pay for most of it causes overuse of medicine and the inflation we are seeing in health insurance premiums.”mclever pointed me in the direction of a study that found that low copays did not actually increase unnecessary medical treatment. I was surprised to learn that, but it is one of many instances where the reality of economics doesn’t line up with oversimplified models. In this case, the natural desire most people have to not see a doctor is a much greater force than the economic one.So what happens instead is that people who should be getting early treatment aren’t getting it, because of those copays or high deductibles. And the net result is much worse, both in terms of health and in terms of money.Second, you said: “The Obamacare requirement that insurers cover preexisting conditions allows the uninsured to hop on and off insurance only during times of sickness.”Perhaps it does, though if so it’s easy to correct. Make the tax credit dependent upon no lapses in coverage, with a possible exception for cases where the insurance was terminated by someone other than the insured (e.g., the employer or insurance company goes out of business).You also make a few claims as if they were fact:1) That the fraud rate in Medicare and Medicaid is “massive.” First, what constitutes “massive,” and second, what’s the evidence you have that this is true?2) Most other nations ration health care. By this, I assume you mean that they ration it in a way that is different from the way that insurance companies do so today. Again, this cries for evidence. You have two things you need to do here. First, list the nations you’re including in the “most” list. Second, provide the evidence that those nations ration health care in a different way than insurance companies do today.I’ll help you out on that one, by the way. The UK does ration health care, based on actuarial data associated with the amount of projected life remaining. But that’s one country, out of 239 (as recognized by the ISO).

  79. Bart DePalma says:

    Michael:1) Forbes was one of the first companies to offer the hybrid of catastrophic health insurance and a HSA where folks were allowed to keep the savings. The growth in their health insurance costs fell dramatically. Medical care is about the only good that we take out of the realm of individual cost/benefit analysis. This needs to be reversed.2) “Make the tax credit dependent upon no lapses in coverage.”The tax credit is miniscule compared to the money you can save by foregoing paying for health insurance at all until you need health care.There is also the problem that the Constitution nowhere grants Congress the power to compel you to buy a good or service. That is why I suggested that health insurance be made a government tax financed public good.3) There are a variety of government studies on the subject, but 60 Minutes recently reported on the $60 billion in Medicare fraud. That is massive.http://www.newsbusters.org/blogs/noel-sheppard/2009/10/25/60-minutes-medicare-fraud-raises-troubling-questions-about-our-govern4) Rationing: The only alternative to our overuse of medical care and health insurance inflation is rationing. The choice we have to make is whether to give that decision to a private insurer, a public insurer or return much of it to the consumer through a HSA. I prefer to make my own decisions, thus my preference for my current HSA and my rage at Obamacare’ outlawing of my HSA in favor of its Medicare health care evaluation board’s (Palin’s Death Panel) rationing decisions.

  80. shortchain says:

    Bart,When discussing the amount of fraud and waste, a simple dollar amount is a misleading statistic. For example, the total paid out last year in Medicare and Medicaid (the vast majority in Medicare) was almost 600 billion dollars.The 60 billion figure claimed in that article you link to is not backed up by an actual study. It’s a worst-case figure created by somebody with an axe to grind, passed along by journalists with a story to sell.So, in the worst case (assuming we can take these people’s claims as accurate) is 10 percent. That’s high, but not catastrophic. It needs to be reduced. But you’ll never get it to zero.If you somehow think private insurance doesn’t have a fraud and waste problem, you have a problem.Finally, rationing is hardly the only way to reduce the cost of health care. One way, for example, would be to spend money and automate a lot of the routine stuff. As it is, we spend a lot of money on salaries for people who do routine things. Perhaps it’s time to think about making medicine a little less payroll-intensive.

  81. Michael Weiss says:

    Bart,I don’t know the specific details of the Forbes policy. Could you enlighten me?Regardless, I don’t have an objection to the HSA/HDI model in principle, though in practice I have some concerns about it raising moral hazards, similar to your objections to the in-and-out model of insurance coverage.What do you think is an appropriate size for the tax/credit? $4,000/year per family is perhaps a little on the low side in my estimation, but “miniscule” seems quite an exaggeration.You said “There is also the problem that the Constitution nowhere grants Congress the power to compel you to buy a good or service. That is why I suggested that health insurance be made a government tax financed public good.”The irony here is that your suggestion is, in effect, what PPACA would have provided with the public option. What we do have is pretty close, insofar as you can get a refund on your public-financed insurance by purchasing private insurance.Regarding the Medicare fraud number you supplied, shortchain is correct regarding the questionable nature of the $60B number. And even if it’s correct, you provided it in a vacuum. It’s about 12% of total Medicare expenditures.Two missing data points immediately come to mind. First, how does the fraud number compare with private insurance? Second, is any additional fraud in Medicare offset by the lower administrative costs?Absent the additional data, your assertion is meaningless.Finally, you say that “The only alternative to our overuse of medical care and health insurance inflation is rationing.” I disagree. There’s a difference between providing fiscal incentives and establishing legal mandates. What’s wrong with providing fiscal incentives to encourage more efficient use of the health care system?

  82. Monotreme says:

    Someone please correct me if I’m wrong, but when Bart says:thus my preference for my current HSA and my rage at Obamacare’ outlawing of my HSA in favor of its Medicare health care evaluation board’s (Palin’s Death Panel) rationing decisions.Does that not translate to:1. The law moved his savings from pre-tax (i.e. tax-free) to taxable. Apparently, he feels this is tantamount to “outlawing” a savings account. This would be news to my credit union, which happily accepts my after-tax income that I can later use for health care — or anything else.2. There is no such thing as a “Death Panel” or rationing decision in the health legislation as passed. The provision in question was inserted by Sen. Isakson (Republican of Georgia), who called the Palin claims “nuts”.I happen to personally feel that rationing is best done in a (forgive the expression) rational way, rather than leaving that decision to the vicissitudes of an insurance company executive. Apparently, other people prefer to have insurance company executives making that decision for them and don’t call that “rationing”. I do. The fact is, “rationing” as defined above already exists in a much more invidious and less transparent form.

  83. shortchain says:

    Monotreme,My HSA appears to be going exactly as it did before, with tax-deductible contributions, no less, so Bart’s claim is a mystery to me as well.I think Bart is referring to the limits on the amount that can be contributed, before taxes, to an FSA, (down from 5000 to 2500, it seems), and to the new rules that don’t allow FSA/HSA money to be spent on OTC material.Or it may be just rampant right-wing paranoia.Take your pick.Since Bart never really explains the claim, it’s pretty much impossible to verify.

  84. shrinkers says:

    Yes, my HSA has not changed at all. I’m contributing the max ($512 / month for both myself and my wife), and it is all pre-tax.Frankly, I’d love it if this monstrosity was outlawed. I’d much rather have something like a traditional insurance policy. In addition to my %6000 / year contribute to HSA, my employer will make up the other $6000 of my deductible before the insurance — for which I pay $400 / month — pays anything at all.There are some changes to be phased in over the next few years. I’m anxious to see them happen.

  85. Pingback: The GOP Healthcare Alternate Universe | 538 Refugees

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