[HopeAndChange44]

Just because I have different ideas about how to improve medical care in this country doesn't mean I'm a soulless Randroid, PMAN. Get over it. I'm sorry that your wife couldn't get health insurance, but there are better ways to fix that which don't involve forcing insurers to cover clients at a guaranteed loss. It's a band-aid fix that isn't going to turn out well, and along with it we're getting an avalanche of shitty tangential legislation that's going to fuck shit up even worse. I'm not saying it's all bad, but it seems like more bad than good and it will be even worse in practice as administered by our utterly dysfunctional government. I'm not defending boneheaded insurance companies or even my own wallet, just being practical about a system that unfortunately has to operate within the confines of our real, imperfect world.

[Jeff Fries]

HopeAndChange44, 30 March 2010 - 03:14 AM:

Just because I have different ideas about how to improve medical care in this country doesn't mean I'm a soulless Randroid, PMAN. Get over it. I'm sorry that your wife couldn't get health insurance, but there are better ways to fix that which don't involve forcing insurers to cover clients at a guaranteed loss. It's a band-aid fix that isn't going to turn out well, and along with it we're getting an avalanche of shitty tangential legislation that's going to fuck shit up even worse. I'm not saying it's all bad, but it seems like more bad than good and it will be even worse in practice as administered by our utterly dysfunctional government. I'm not defending boneheaded insurance companies or even my own wallet, just being practical about a system that unfortunately has to operate within the confines of our real, imperfect world.

Well what are your ideas chump

[HopeAndChange44]

Jeff Fries, 30 March 2010 - 04:47 AM:

HopeAndChange44, 30 March 2010 - 03:14 AM:

Just because I have different ideas about how to improve medical care in this country doesn't mean I'm a soulless Randroid, PMAN. Get over it. I'm sorry that your wife couldn't get health insurance, but there are better ways to fix that which don't involve forcing insurers to cover clients at a guaranteed loss. It's a band-aid fix that isn't going to turn out well, and along with it we're getting an avalanche of shitty tangential legislation that's going to fuck shit up even worse. I'm not saying it's all bad, but it seems like more bad than good and it will be even worse in practice as administered by our utterly dysfunctional government. I'm not defending boneheaded insurance companies or even my own wallet, just being practical about a system that unfortunately has to operate within the confines of our real, imperfect world.

Well what are your ideas chump

Here are a few:

Raise Medicare and Medicaid reimbursement rates to 100%. It would look like a budget nightmare, and would probably require a dreaded middle-class tax hike (or maybe we could shave off some of the mortgage interest tax deduction). But ultimately it would drastically reduce the cost of medical care for people in the private system, and would probably be neutral or beneficial in terms of total dollars spent.

Require insurers to offer actuarially sound long-term guaranteed-issue portable insurance plans and perform rigorous physicals before issuing insurance, and ban rescission. For people who can't currently get affordable insurance, the government would have a one-time "insurance amnesty" lump-sum payout to help get them enrolled in a long-term plan. This would have the added effect of encouraging providers to move away from the fee-for-service model and toward a more outcome-based approach.

Implement tariffs, taxes, trade agreements, and allow drug re-importation so that medical research companies stop abusing our system and treating us like a piggy bank for medical innovation. Right now we're paying a massive premium for the dubious benefits of being early adopters and spurring innovation, much of which occurs (and thus produces jobs and tax revenues) outside the US.

Break down inter-state barriers to increase competition. Adopt bare-bones minimum standards at the federal level and rigorously enforce them, but otherwise give insurance companies and customers lots of leeway in negotiating plans. I know people in other states who fit my profile who have to pay a lot more than I do because of legislative interference. Unfortunately this is likely to run into the "stupid consumer" problem, so some kind of transparency, "plain language", and other consumer protections would have to be added. I generally prefer state government to federal government, but this is one case where the states have proven too easily gamed. Also federalize malpractice laws, increase doctor protections, and otherwise disincentivize "defensive medicine".

Tax benefit plans including health care as if they were direct monetary compensation. This would help us move away from employer-based insurance and also stick it to all those unionized government employees who command outrageous benefit packages in addition to their already bloated salaries.

These ideas together would move us toward a better system - that is to say a system with less waste, less graft, less uncertainty, and better outcomes. People could pay a stable premium regardless of their health condition with flexibility to switch providers, doctors would be rewarded for performance rather than productivity, and insurance companies wouldn't have to play games with their customers.





All that aside, I wouldn't be completely against a government-run communist (or communal, if you prefer) health system like they have in Britain EXCEPT that our higher-ups seem hell-bent on importing millions of illiterate third-world peasants who seem capable of nothing more than replicating themselves exponentially, not to mention truckloads of AIDS-infected African refugees, and lots of foreign doctors (jobs Americans won't do) who don't give a fuck whether I live or die. I'd be happy with paying higher taxes or premiums to help PMAN's wife get medical care, but I'm not so crazy about chipping in for a family-reunified Filipino granny's dialysis. I certainly don't think businesses can do no wrong but when choosing between a corporation that just sees me as a dollar sign versus a hopelessly incompetent government that seems increasingly hostile to me as a straight white male, I'll choose the corporation.

[PLEASUREMAN]

HopeAndChange44, 30 March 2010 - 04:14 AM:

Just because I have different ideas about how to improve medical care in this country doesn't mean I'm a soulless Randroid, PMAN. Get over it. I'm sorry that your wife couldn't get health insurance, but there are better ways to fix that which don't involve forcing insurers to cover clients at a guaranteed loss. It's a band-aid fix that isn't going to turn out well, and along with it we're getting an avalanche of shitty tangential legislation that's going to fuck shit up even worse. I'm not saying it's all bad, but it seems like more bad than good and it will be even worse in practice as administered by our utterly dysfunctional government. I'm not defending boneheaded insurance companies or even my own wallet, just being practical about a system that unfortunately has to operate within the confines of our real, imperfect world.

This wasn't directed at you, but this post does indicate something of what I am talking about. "Forcing insurers to cover clients at a guaranteed loss"--which while I am no supporter of "Obamacare" is not what this legislation does--is pure insurance industry propaganda, which the people at NR, Weekly Standard, and thousands of blogs freely propagate, many of them knowing on some level that it is propaganda. Mind you, it's propaganda in the face of legislation that is a huge giveaway to insurance companies by subsidizing their rate increases (which the government has the temerity to regulate!) and furthering restricted employer-provided care that benefits the insurance industry. To say they are victims of this legislation is the kind of lunacy that conservatives freely spout without even thinking about it. They just know it's true.

As I pointed out in our chat, America pays more in healthcare per capita than any other Western nation--more than twice as much and sometimes three times as much! That conservatives have no real response to this--control of Congress since '94 and eight years of Bush passed with not the slightest effort to do anything about it--tells you all you need to know about the conservative mind. They can only rage when someone else attempts to address this issue, while contributing no solutions of their own, except hurried, piecemeal alternative plans intended to scotch impending legislation.

The extra money Americans pay is in effect a huge tax that goes to support insurance company profits, lawsuit payouts, and the other middle industries (such as excessive testing) created by a variety of perverse incentives. To any sane person, the continued escalation in costs for even low quality and highly restricted care we have now is unsustainable. The conservative response is mainly, "AMERICA HAS THE GREATEST HEALTHCARE IN THE WORLD BOOYAH!" which isn't even true by any available metric of life quality or life expectancy.

Conservatives cannot see that this aggressive profit-taking--often regressive in nature since the poor and uninsured are charged more for the same healthcare--as damaging to the stability of society, just as they can't see the dangers of their extreme stance on free trade. But this is no surprise--conservatives are reflexive toadies to anyone with money.

Conservatives know, as Dr. Pangloss might say, that a free market produces the best of all possible worlds. This belief, which has nothing to do with the real world, has become the motto of the conservative idiot.

[PLEASUREMAN]

By the way the only alternative is not the socialized medicine of Canada or Britain--which we are nowhere close to having, at any rate, and it is purely mindless to say we are. There have been many other implementations of reform throughout Europe (France and Germany both have workable but very different systems), but of course this will come as news to those of us who get our information from the American conservative establishment, which through its actions has ironically set us on a path where we are more likely to be stuck with some American twist on the Canadian system (awful as it is).

[PLEASUREMAN]

Since I mentioned in passing the circumstances of my wife, I'll provide fuller details here. After quitting my last job and becoming self-employed I needed to buy insurance for myself and my wife. This meant going through the high deductible plans on offer (as an aside, high deductible plans have the added benefit of forcing people to think about their healthcare spending--low deductible plans encourage uninformed consumption). We opted for Blue Cross' coverage, and filled out all the long forms on our health histories, which is of course something people on employer-provided plans do not normally have to do.

They came back and rejected my wife because she had had an esophagal ulcer a couple of years ago, which had long since been treated and was only discovered in the first place because I wanted her to get checked out for some stomach discomfort to make certain nothing serious was wrong with her. Ulcerations are far from uncommon and this one had nothing to do with the initial complaint--it is the sort of thing often found by preventative care. We then went through a typical bureaucratic nightmare with Blue Cross and her physician, making follow-up appointments, faxing doctor letters and exam results, requesting a review, and so on to the apathetic and not very bright customer service staff at Blue Cross.

What was evident was that Blue Cross uses arbitrary flags to screen out applicants who might actually need healthcare (if you can imagine such an outrage). Of course this is a product of a system designed to maximize profits, something conservatives will lecture long and loud in favor of as a God-given right of business enterprises. From my perspective it was a pointless, idiotic, Kafka-esque experience which didn't even have the effect that Blue Cross intended (as my wife is actually perfectly healthy, they stood to profit more from taking her on as a customer than by rejecting her over a trivial event in her medical history). This is a system that is operating on stupid principles for amoral ends--which conservatives will defend with their last breath!

Medical costs of course are such (have been allowed to become such) that even nominal treatment of any serious problem is unaffordable without health insurance--so declining coverage will be enough to either deprive people of any hope of treatment or force them into bankruptcy. Of course the point of an insurance system is that it spreads risk (cost) around.

It is easy to overlook in this the reality that insurance companies offer cheap coverage through employers to people far more at risk of needing expensive medical care than my wife ever was, which gives the lie to their claims that they must be allowed to restrict individual coverage to only those in the full flush of health or else risk bankruptcy. They offer affordable coverage to people who are poor risks and make handsome profits doing so. Keep this in mind when conservatives scream with rage about "Obamacare".

Of course my wife and I ended up getting coverage through another company, at only a slightly higher rate. This is in effect what Blue Cross was aiming to achieve--pushing someone with an arbitrarily designated risk factor off on someone else, so their customer base is that much healthier, which furthers profits. Somewhere a conservative is smiling!

[HopeAndChange44]

PLEASUREMAN, 30 March 2010 - 10:55 AM:

they stood to profit more from taking her on as a customer than by rejecting her over a trivial event in her medical history

PLEASUREMAN, 30 March 2010 - 10:55 AM:

Of course my wife and I ended up getting coverage through another company, at only a slightly higher rate. This is in effect what Blue Cross was aiming to achieve--pushing someone with an arbitrarily designated risk factor off on someone else, so their customer base is that much healthier, which furthers profits.

So they stood to profit from her, but they denied her in order to increase profits? What you're describing isn't greedy, it's just stupid. Stupid business loses customer due to bad business practice - sounds like the market worked.

Anyway, Blue Cross is at least nominally a nonprofit and its top 5 executive salaries combined amounted to about $3 per customer. Since they have 15 million customers, I can understand why they might have partially automated their screening process. In the end you got health insurance from a different company, so it doesn't seem like you have much to complain about here.

I'm not going to assert moral purity on behalf of the insurance industry, but I feel they are being unfairly singled out in this and the broader discussion of the problems with our health care industry. Pharmaceutical company profits dwarf those of insurance companies by an order of magnitude. The other middlemen you mentioned, as well as those I mentioned, are also major contributors to the dysfunction. I don't think the insurance companies are really responsible for our outrageous health care expenditures, they're just the people who send us the bill.

With regard to insurance companies being forced to accept clients at a loss, I didn't get that from any mainstream conservative publication. I merely inferred it from the Democrat rhetoric about ending "discrimination" against people with pre-existing conditions. I know that they were probably full of shit, but since I don't know what the bill actually says in this regard I'm just taking their word for it. I'll see if I can find out what's really in there.

[PLEASUREMAN]

You just said that Blue Cross' top five executive salaries add up to $45 million dollars (if this is true it's deeply scandalous)--yet you think they're being unfairly singled out? These companies don't do anything except act as banks for healthcare funds--of all the components of the healthcare industry, they're the ones doing no-brainer work, and are essentially comprised of accountants, lawyers, and call centers--the unholy trinity you will find running most borderline exploitative businesses.

One of the concepts that conservatives have a profound difficulty understanding--and I find this quite strange--is that businesses have moral and ethical obligations. The vibe I routinely get from modern conservatives is that this does not compute--they can and should be free to do whatever they want, even if it is destructive to the communities they operate in. Again we return to the notion that "what is legally permissible is morally permissible" as a central tenet of modern society.

Blue Cross--like other businesses, but especially those which serve important public interests--has the social obligation to do its business in a manner consistent with the values that allow society to prosper (and hence allow Blue Cross to make money). But the fact is that Blue Cross' management works mainly to award itself grotesque salaries and bonuses. The modern conservative will of course say, "THAT'S THEIR RIGHT YOU MONSTER!" or make some useless noise about how the market will correct for this (he should perhaps look at the plethora of industries in which the market consistently fails to correct for this behavior--such as the healthcare industry).

Have you ever heard a conservative talk about the responsibilities of business? You might find the odd paleo saying something like it, but it is a notion that has mostly vanished from modern conservative discourse--and we sneer gleefully when liberals talk about it.

The healthcare industry isn't fulfilling any such responsibility--it operates for other reasons, and then cries when the result of its behavior causes the government to crash its orgy. As in the pathetic article I linked to, conservatives will cry long and loud about how doctors, pharmaceutical companies, insurance companies, et al are being unfairly punished--how they should be allowed to exploit their markets further by selling worthless plans to people foolish enough to buy them. It's the morality of the con artist--is that what conservatism now stands for?

[HopeAndChange44]

PLEASUREMAN, 30 March 2010 - 03:09 PM:

You just said that Blue Cross' top five executive salaries add up to $45 million dollars (if this is true it's deeply scandalous)--yet you think they're being unfairly singled out?

My point was that when the top levels of management are only earning $3 per customer, it doesn't make sense to blame their "greed" for the massive rate hikes of their companies. If they raised rates by 20% and pocketed the entire excess themselves, they'd be making billions. I quoted the $3 per customer number to suggest that the funds raised by their "unconscionable" rate hikes are mostly going to other players. $45 million sounds ridiculous to working stiffs like you and me, and they are certainly grossly overpaid, but it's just a drop in the bucket when you're talking about a $17 billion a year business. Like I said, Pharma profits make these execs look like paupers and there are many other actors who earn more and contribute much less.

FYI, here's where I got the numbers.

[HopeAndChange44]

PLEASUREMAN, 30 March 2010 - 03:09 PM:

The modern conservative will of course say, "THAT'S THEIR RIGHT YOU MONSTER!" or make some useless noise about how the market will correct for this.

Good point. I don't know anyone who left Blue Cross because of their bad business practices and enrolled with a different provider. The market clearly doesn't work because there are no alternatives.

[PLEASUREMAN]

HopeAndChange44, 30 March 2010 - 03:45 PM:

PLEASUREMAN, 30 March 2010 - 03:09 PM:

The modern conservative will of course say, "THAT'S THEIR RIGHT YOU MONSTER!" or make some useless noise about how the market will correct for this.

Good point. I don't know anyone who left Blue Cross because of their bad business practices and enrolled with a different provider. The market clearly doesn't work because there are no alternatives.

I think you're smarter than this.

[PRCalDude]

Quote

They came back and rejected my wife because she had had an esophagal ulcer a couple of years ago, which had long since been treated and was only discovered in the first place because I wanted her to get checked out for some stomach discomfort to make certain nothing serious was wrong with her. Ulcerations are far from uncommon and this one had nothing to do with the initial complaint--it is the sort of thing often found by preventative care. We then went through a typical bureaucratic nightmare with Blue Cross and her physician, making follow-up appointments, faxing doctor letters and exam results, requesting a review, and so on to the apathetic and not very bright customer service staff at Blue Cross.

I go back and forth with my old man about this all the time. "Dad," I tell him, "when I hurt my neck and had all those other problems, my health insurance didn't do anything for me. I ended up paying for a bunch of tests myself." When health insurance comes out to $3k per person per year (or whatever it is now), couldn't we just save that money ourselves and go to a cash system completely? It seems to me that we could. An MRI is $300 cash. It's like $1500 reimbursed through health insurance. You can't "insure" health care anyways. It's something for which there is essentially limitless demand and all it does is create moral hazard for the slow-bellies and fatties who refuse to do any preventative maintenance knowing they can shift the cost onto others.

I say we go to a cash system like we used to have. I'll save my money and donate money to those in my church who have health problems. The elders can dole it out as they see fit through the diaconal offering. All health insurance does is create deadweight losses and pit providers against their patients. I see no benefits. Costs have only soared under health insurance, Medicare and Medicaid.

[PRCalDude]

Quote

Raise Medicare and Medicaid reimbursement rates to 100%. It would look like a budget nightmare, and would probably require a dreaded middle-class tax hike (or maybe we could shave off some of the mortgage interest tax deduction). But ultimately it would drastically reduce the cost of medical care for people in the private system, and would probably be neutral or beneficial in terms of total dollars spent.

The middle class pays enough. We don't have the money to fund yet another entitlement Ponzi scheme. The only way nationalized health care can reduce costs is through restricting supply of health care through price fixing and by paying providers less, which also restricts supply. This is basic microeconomics. It probably would reduce costs at a reduction of quality and supply. It would also add an enormous deadweight loss due to government intervention. (See: Mankiw, "Microeconomics"). Perhaps the most cogent argument against nationalized health care is the sheer amount of blacks and hispanics in government employment. Imagine calling up the local nationalized health care office and speaking to Shaniqua about some health coverage issue. You're essentially inviting the same people who run the IRS and other incompetent bureaucracies to run your health care. Scary.

Quote

Require insurers to offer actuarially sound long-term guaranteed-issue portable insurance plans and perform rigorous physicals before issuing insurance, and ban rescission. For people who can't currently get affordable insurance, the government would have a one-time "insurance amnesty" lump-sum payout to help get them enrolled in a long-term plan. This would have the added effect of encouraging providers to move away from the fee-for-service model and toward a more outcome-based approach.

"Fee for service" is the way the invisible hand works. The doctor can lecture you all day long about how you need to lose weight, start exercising, quit smoking, and start eating right. Most of the chronic, costly type II diabetes cases are entirely preventable, for instance. But most people simply have mental and psychological blocks preventing them from taking appropriate action to prevent chronic preventable illnesses like heart disease and diabetes. How can shifting the burden onto providers change this? It's like blaming teachers for black and hispanic academic failure.

Quote

Implement tariffs, taxes, trade agreements, and allow drug re-importation so that medical research companies stop abusing our system and treating us like a piggy bank for medical innovation. Right now we're paying a massive premium for the dubious benefits of being early adopters and spurring innovation, much of which occurs (and thus produces jobs and tax revenues) outside the US.

Agreed with this and following.

One thing that might actually help doctors is getting the drug reps out of their offices, though. Doctors need to learn to think beyond writing a prescription for nearly everything. But we'd have to break up Big Pharma cartels for that.

We know that SSRIs and many of the other drugs invented over the past 20 years are harmful or have no benefit. Pharmacology needs to be assigned a much lower standard in medical practice. Artificial menopause hormones are another example of Big Pharma harming us (women, actually). Bioidentical hormones need no invention and are much safer than hormone medicines derived from horses which lead to cancer, but they don't produce drug company profits.

Somehow, the collusion between medical practice and Big Pharma is causing doctors to stop using their brains.

[PLEASUREMAN]

PRCalDude, 30 March 2010 - 08:19 PM:

I go back and forth with my old man about this all the time. "Dad," I tell him, "when I hurt my neck and had all those other problems, my health insurance didn't do anything for me. I ended up paying for a bunch of tests myself." When health insurance comes out to $3k per person per year (or whatever it is now), couldn't we just save that money ourselves and go to a cash system completely? It seems to me that we could. An MRI is $300 cash. It's like $1500 reimbursed through health insurance. You can't "insure" health care anyways. It's something for which there is essentially limitless demand and all it does is create moral hazard for the slow-bellies and fatties who refuse to do any preventative maintenance knowing they can shift the cost onto others.

I say we go to a cash system like we used to have. I'll save my money and donate money to those in my church who have health problems. The elders can dole it out as they see fit through the diaconal offering. All health insurance does is create deadweight losses and pit providers against their patients. I see no benefits. Costs have only soared under health insurance, Medicare and Medicaid.

In a sense this is what I was alluding to in mentioning high deductible plans. High deductible plans allow you to have relatively affordable coverage for big things like hospital stays that easily run into the tens of thousands or more and are very unpredictable. But for most things you pay the negotiated rate (which actually is much cheaper than cash--my understanding is that if you don't have insurance you will pay much more for almost everything because you are paying sticker price). This encourages more judicious use of health care and would if widely adopted force providers to be more competitive on price--in theory.

But you still need the coverage both for the negotiated rates and the catastrophic coverage you get. The insurance component should work when it deals with rare problems--it does not work when you try to make it pay for everything, obviously. And untethering it from employment is highly desirable, because it needs to be portable and people need to have a sense that this is like a utility, something they should always expect to budget for and manage themselves, not something that they just hope their employer settles to their liking.

[PRCalDude]

PLEASUREMAN, 30 March 2010 - 06:53 PM:

PRCalDude, 30 March 2010 - 08:19 PM:

I go back and forth with my old man about this all the time. "Dad," I tell him, "when I hurt my neck and had all those other problems, my health insurance didn't do anything for me. I ended up paying for a bunch of tests myself." When health insurance comes out to $3k per person per year (or whatever it is now), couldn't we just save that money ourselves and go to a cash system completely? It seems to me that we could. An MRI is $300 cash. It's like $1500 reimbursed through health insurance. You can't "insure" health care anyways. It's something for which there is essentially limitless demand and all it does is create moral hazard for the slow-bellies and fatties who refuse to do any preventative maintenance knowing they can shift the cost onto others.

I say we go to a cash system like we used to have. I'll save my money and donate money to those in my church who have health problems. The elders can dole it out as they see fit through the diaconal offering. All health insurance does is create deadweight losses and pit providers against their patients. I see no benefits. Costs have only soared under health insurance, Medicare and Medicaid.

In a sense this is what I was alluding to in mentioning high deductible plans. High deductible plans allow you to have relatively affordable coverage for big things like hospital stays that easily run into the tens of thousands or more and are very unpredictable. But for most things you pay the negotiated rate (which actually is much cheaper than cash--my understanding is that if you don't have insurance you will pay much more for almost everything because you are paying sticker price). This encourages more judicious use of health care and would if widely adopted force providers to be more competitive on price--in theory.

But you still need the coverage both for the negotiated rates and the catastrophic coverage you get. The insurance component should work when it deals with rare problems--it does not work when you try to make it pay for everything, obviously. And untethering it from employment is highly desirable, because it needs to be portable and people need to have a sense that this is like a utility, something they should always expect to budget for and manage themselves, not something that they just hope their employer settles to their liking.

Wouldn't "catastrophic" medical bills be much less catastrophic without government/corporate meddling in prices? Essentially what we have now is many people paying zero and the rest of the cost shifted onto those who do pay with added DW losses and other price fixing malfeasance.

At the end of the day, though, we will surely go back to a cash system. It's inevitable. There will be two tiers: cash and government care. If I need an expensive elective surgery, there's always India.

[PLEASUREMAN]

PRCalDude, 30 March 2010 - 10:33 PM:

Wouldn't "catastrophic" medical bills be much less catastrophic without government/corporate meddling in prices? Essentially what we have now is many people paying zero and the rest of the cost shifted onto those who do pay with added DW losses and other price fixing malfeasance.

At the end of the day, though, we will surely go back to a cash system. It's inevitable. There will be two tiers: cash and government care. If I need an expensive elective surgery, there's always India.

In general every aspect of health care is broken due to lack of regulation and poor incentives. How do you make long-term care work in a cash system? What about treatment you want people to have access to (perhaps drug counseling, basic preventative care)? It's a complicated subject but there is no way health care is attainable for most families on a cash basis--it's not really an option. This has to do with the way people think as much as the costs involved (Fooled by Randomness delves deeply into why people mis-estimate risks and inadequately plan for them). Compulsory insurance is one of the few parts of the recent legislation that makes sense.

[PRCalDude]

PLEASUREMAN, 31 March 2010 - 08:34 AM:

PRCalDude, 30 March 2010 - 10:33 PM:

Wouldn't "catastrophic" medical bills be much less catastrophic without government/corporate meddling in prices? Essentially what we have now is many people paying zero and the rest of the cost shifted onto those who do pay with added DW losses and other price fixing malfeasance.

At the end of the day, though, we will surely go back to a cash system. It's inevitable. There will be two tiers: cash and government care. If I need an expensive elective surgery, there's always India.

In general every aspect of health care is broken due to lack of regulation and poor incentives. How do you make long-term care work in a cash system?

How did it work before? I think people simply weren't living as long. What typically happens is that someone will become incapacitated due to a stroke or some other chronic illness and then linger half-dead for several years costing thousands (if not hundreds of thousands). Do I think people deserve care? Absolutely, though I don't think the 6th commandment applies to people who are basically dead without machines keeping them alive. But there's simply no way to get government involved and have things work out. Government already pays for something like 60% of all medical expenses in this country, and the percentage has increased linearly since the 1960s. How's it working for us now? We think cash would be so bad, but I think it at least means more freedom.

Quote

What about treatment you want people to have access to (perhaps drug counseling, basic preventative care)? It's a complicated subject but there is no way health care is attainable for most families on a cash basis--it's not really an option. This has to do with the way people think as much as the costs involved (Fooled by Randomness delves deeply into why people mis-estimate risks and inadequately plan for them). Compulsory insurance is one of the few parts of the recent legislation that makes sense.

People mis-estimate risks all the time. That's true. But you're proposing a statist solution. Let people decide for themselves and let the chips fall where they may. Only the conscientious will pursue preventative maintenance and health risk management anyway. Proles don't care.

I know my family lived without "health insurance" for at least 100 years in this country. "Health insurance" is a new thing. Why do we think we can't do without it?

I don't think government coercion of individuals is the way to go. Sooner or later, they'll start coercing you to buy something else. It's a pretty scary idea, actually.

[PLEASUREMAN]

I'm not proposing a statist solution. The French system for example is not statist. Look, we are spending more than twice as much as other countries and getting nothing for it. Before we start having Peter Singer-inspired conversations about when is the right time to put a bullet in Grandma, we should address that problem.

Moreover, I doubt very much of the cost is incurred by bedridden hospital patients hooked up to banks of machines with blinking lights and a big on/off switch sitting on the nightstand. We're paying for a lot of professional analysis, new drug regimens (and the research and testing they require), advanced diagnostic equipment, and the fact that we are curing people so they can live longer and get more problems. We're also finding more things such as benign tumors that we operate on anyway "just to be safe". It's not a simple decision to draw a line at age 80 and say after that you're on your own. People who used to die at 50 are living much longer and consuming more healthcare. This is besides the question of the premium we pay for the right to sue for a fortune over every conceivable foul-up (and really if you're the guy who gets the wrong leg amputated, I sympathize).

The truth is, people want to spend a lot of money on their healthcare. I know when it comes right down to it I will too. For the amount we're already spending we should be getting more than we are getting.

[PRCalDude]

Whoa, no one's talking about putting a bullet in grandma. I'm just saying that there are the living and then there are the "living." I'm also suggesting that people be "on there own" (that is, paying cash), from the beginning. I think it would drive costs down for everyone. Some people would be left out, but many more would benefit.

The machines DO cost a lot of money, btw. The cost is amortized patient-by-patient.

The truth is probably that neither of us understands the issue very well at all. I'm proposing more simplicity by going to cash. I don't think the added layers of complexity will get us anywhere. It's already so complex no one understands it. Sowell wrote a series of articles that you and I should probably read:
http://econlog.econl...l_on_healt.html

Either way, I don't necessarily think I'd spare no expense if I had a really serious problem. I might opt for death depending on where I am in life, how much debt I'm likely to incur due to medical bills, how much I'm likely to earn if I survive, etc. I might be worth more dead than alive. It's certainly my right to choose.

This post has been edited by PRCalDude: 31 March 2010 - 10:57 PM

[Voedsel Gemotiveerd]

PLEASUREMAN, 31 March 2010 - 10:39 PM:

I'm not proposing a statist solution. The French system for example is not statist. Look, we are spending more than twice as much as other countries and getting nothing for it. Before we start having Peter Singer-inspired conversations about when is the right time to put a bullet in Grandma, we should address that problem.

Moreover, I doubt very much of the cost is incurred by bedridden hospital patients hooked up to banks of machines with blinking lights and a big on/off switch sitting on the nightstand. We're paying for a lot of professional analysis, new drug regimens (and the research and testing they require), advanced diagnostic equipment, and the fact that we are curing people so they can live longer and get more problems. We're also finding more things such as benign tumors that we operate on anyway "just to be safe". It's not a simple decision to draw a line at age 80 and say after that you're on your own. People who used to die at 50 are living much longer and consuming more healthcare. This is besides the question of the premium we pay for the right to sue for a fortune over every conceivable foul-up (and really if you're the guy who gets the wrong leg amputated, I sympathize).

Yea I'm pretty sure I've read that nearly all of the "twice as much" we spend vs. everywhere else comes from keeping our grandparents alive for a few more years/days/hours. Almost all those expensive new drugs, analysis, testing, equipment goes towards heathcare for the 75+ crowd while the Euros save that cash by free-riding off our innovation dime and parking their grandparents in hospice care.

It's like how they keep their infant mortality rates low by not stuffing every barely alive fetus into an incubator. American healthcare "sucks" on paper because we don't cut those sketchy corners like everyone else.

It just seems like if you mess up the part that's working(everything up to the last years) while not dealing with the real money sink we're all going to be dramatically worse off.