ACA Lives For Another Year

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elasto
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Re: ACA Lives For Another Year

Postby elasto » Sun Mar 26, 2017 12:58 pm UTC

The Great Hippo wrote:
elasto wrote:But they would say that that's because they have to cover the cost of developing the treatment - including all the attempts at treatment that didn't succeed - and all the costly trials therein.
And they'd be lying.

Just compare costs in the states to anywhere else.

Yes, but the tradeoff is that US patients get cutting edge medicines and treatments before other countries generally do.

In a sense, as early adopters, US patients subsidise the price subsequently offered to other markets.

(The price then remains high in the US due to insurance companies having an inherent conflict of interest over pricing: They make more money the more expensive treatments get - because they cover their costs then add a fixed percentage for profit, so why drive a hard bargain?

OTOH, because a country like the UK negotiates on a pragmatic 'take it or leave it' basis, they can credibly threaten the company that if they charge too much they simply wont buy. So the company usually compromises - because any additional revenue from secondary markets is basically pure profit.)

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Re: ACA Lives For Another Year

Postby Dark567 » Sun Mar 26, 2017 1:37 pm UTC

The Great Hippo wrote:It's not as if there's some sort of critical shortage re: cancer treatment; someone getting chemo doesn't mean someone else can't. That's why it seems kind of fucked up to me to talk about this in terms of how much we're willing to spend to save a life -- the only reason we're even having that conversation is because somebody decided it's okay to charge hundreds of thousands of dollars for cancer treatment.
I don't think that is correct. Somebody getting cancer treatment very well means somebody else may not be getting medical care of some type, although the constraint is not the drugs, but the practitioners. You to an extent even see this with the ACA, although it increased the number of people that have insurance particularly among the poor(note that these are often high deductible plans that discourage you from using healthcare), there was some smaller amount of middle-class people that saw their prices rise and decide to quit their plans or effectively encouraged to less extensive plans(in 2020, the Cadillac tax). Medical care is not something we have an infinite amount of and we are resource constrained. Sure, getting a cancer treatment doesn't necessarily mean someone else can't but it can also mean someone doesn't get to go to an oncologist to get diagnosed or a prescription for chemo or radiology or whatever.
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Re: ACA Lives For Another Year

Postby Dauric » Sun Mar 26, 2017 2:31 pm UTC

Dark567 wrote:
The Great Hippo wrote:It's not as if there's some sort of critical shortage re: cancer treatment; someone getting chemo doesn't mean someone else can't. That's why it seems kind of fucked up to me to talk about this in terms of how much we're willing to spend to save a life -- the only reason we're even having that conversation is because somebody decided it's okay to charge hundreds of thousands of dollars for cancer treatment.
I don't think that is correct. Somebody getting cancer treatment very well means somebody else may not be getting medical care of some type, although the constraint is not the drugs, but the practitioners. You to an extent even see this with the ACA, although it increased the number of people that have insurance particularly among the poor(note that these are often high deductible plans that discourage you from using healthcare), there was some smaller amount of middle-class people that saw their prices rise and decide to quit their plans or effectively encouraged to less extensive plans(in 2020, the Cadillac tax). Medical care is not something we have an infinite amount of and we are resource constrained. Sure, getting a cancer treatment doesn't necessarily mean someone else can't but it can also mean someone doesn't get to go to an oncologist to get diagnosed or a prescription for chemo or radiology or whatever.


While this is true, there remain issues of whether the costs in the U.S. are actually reflective of the market scarcity for those man-hours.In a single facility the price for a specific treatment can vary wildly.

In lower-back MRIs, we found that for CPT code 72148, insurers paid from $467 to $1,567. But when we looked beyond commercial insurers, we found even greater variation — from a low of $255 to a self-pay price of $6,221 at an academic medical center. That $255 MRI was paid by Medicare, and was just a fraction of the facility's charge of $2,450.

But the variation doesn't stop there. Yet another person went to the same facility and was charged $603 for the same procedure, same CPT code. This patient had commercial insurance but paid the entire amount out of pocket, the patient wrote, since "I had not yet met my deductible."


(Linkage to more in-depth article)

Spoiler:
CONAN: How do hospitals figure out how much to charge? I mean, yeah, they have to pay the surgeon, there's so much time in the oper - how do they come up with these amounts?

HSIA: So actually if you look at how they've come up with these prices before, before hospitals were never required to actually know what their costs were. So if you look at, for example, other industries like the auto industry or any other industry, they actually usually know what their costs are. So an automaker will know what it costs to make a car, and they will use usually what's called a cost-plus system, so what does it cost plus the profit margin for, you know, different people along the chain. And that's how they come up with a price.

But hospitals and health care has never been required to have an idea of what the actual costs are. If you ask a hospital CEO what does it actually cost you to take care of a patient who has pneumonia, they actually won't know. And because health care has never been required to basically be accountable for their costs, they come up with these charges very arbitrarily, so based on what they think it should be and what other people say it should be. It's not a cost-plus system at all.
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Re: ACA Lives For Another Year

Postby ucim » Sun Mar 26, 2017 3:08 pm UTC

a spoilered excerpt of an article linked by Dauric wrote:It's not a cost-plus system at all.
No, it's a market based system. They charge what the market will bear. It's hard to compare with cars, as each patient case is different but cars are pretty fungible. It's a bit more like pricing artwork, which is another example of "not a cost-plus" system. Also, being more of a service than a product, the costs are much less material for medical care.

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Re: ACA Lives For Another Year

Postby gmalivuk » Mon Mar 27, 2017 2:31 pm UTC

Dark567 wrote:Millions spent on end of life care in that situation doesn't sound like a good use of resources.
People always love to bring up end-of-life care, as though old folks are the only ones getting expensive medical bills.

To use a personal example, my fairly routine appendectomy and a single hospital stay due to a lingering infection would have cost $45,000 without insurance. Obviously that's nowhere near what a full course of cancer treatment costs, but unlike cancer, appendicitis is by far most common among young adults. The average age is 25 and only 1.3% of people admitted for appendicitis being over the age of 60.
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Re: ACA Lives For Another Year

Postby Dark567 » Mon Mar 27, 2017 2:53 pm UTC

gmalivuk wrote:
Dark567 wrote:Millions spent on end of life care in that situation doesn't sound like a good use of resources.
People always love to bring up end-of-life care, as though old folks are the only ones getting expensive medical bills.

To use a personal example, my fairly routine appendectomy and a single hospital stay due to a lingering infection would have cost $45,000 without insurance. Obviously that's nowhere near what a full course of cancer treatment costs, but unlike cancer, appendicitis is by far most common among young adults. The average age is 25 and only 1.3% of people admitted for appendicitis being over the age of 60.
There are definitely more than old people, but that majority of costs are from middle age and old people.

Besides, it's mostly irrelevant to my point that one of the reasons the US is so expensive is the lack of incentives anywhere in the process to control costs or do any sort of cost benefit based on how long you are expected to live. In most other countries insurance or the government would look at your appendectomy and say "hey, this is a young dude who is expected to live for another 50 years, totally worth 45k".

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Re: ACA Lives For Another Year

Postby Dauric » Mon Mar 27, 2017 3:17 pm UTC

ucim wrote:
a spoilered excerpt of an article linked by Dauric wrote:It's not a cost-plus system at all.
No, it's a market based system. They charge what the market will bear. It's hard to compare with cars, as each patient case is different but cars are pretty fungible. It's a bit more like pricing artwork, which is another example of "not a cost-plus" system. Also, being more of a service than a product, the costs are much less material for medical care.

Jose


Except that it's not really "What the market will bear" so much as what they think the -Individual- will bear. The underlying price for a particular procedure can vary wildly based on your income and what insurance company you have. It has less appearance of free market and more resemblance to extortion.

And let's be honest here, when someone is having to weigh money against their own or their loved one's lives the market value can be terribly skewed (see end of life discussion in this very thread), and those taking advantage of risks to someone life for money treads an easily abusable line.
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Re: ACA Lives For Another Year

Postby Zohar » Mon Mar 27, 2017 3:30 pm UTC

Dark567 wrote:Besides, it's mostly irrelevant to my point that one of the reasons the US is so expensive is the lack of incentives anywhere in the process to control costs or do any sort of cost benefit based on how long you are expected to live. In most other countries insurance or the government would look at your appendectomy and say "hey, this is a young dude who is expected to live for another 50 years, totally worth 45k".


You have to keep in mind in most other countries an appendectomy would cost a lot less than 45K.
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Re: ACA Lives For Another Year

Postby ucim » Mon Mar 27, 2017 3:30 pm UTC

Dauric wrote:Except that it's not really "What the market will bear" so much as what they think the -Individual- will bear.
Yeah, same thing. "The market" is not monolithic.
Dauric wrote:...and more resemblance to extortion.
Amen Brister!
Dauric wrote:...when someone is having to weight money against their or their loved one's lives...
...but that's what all health care is. Except single payer, which is having to weigh their money against a stranger's life.

Doctors "profit from illness". Teachers "profit from ignorance". Bankers "profit from poverty".... Probably the biggest thing that distinguishes health care is that it is most often needed when there are few choices, and because there's even less information, trust is paramount. Anywhere trust is required, abuse is right around the corner.

If you can solve the health care issue, you can probably solve the general problem, and if you can do that, NP completeness falls out of it as a corollary.

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Re: ACA Lives For Another Year

Postby ObsessoMom » Mon Mar 27, 2017 6:10 pm UTC

ucim wrote:
a spoilered excerpt of an article linked by Dauric wrote:It's not a cost-plus system at all.
No, it's a market based system. They charge what the market will bear. It's hard to compare with cars, as each patient case is different but cars are pretty fungible. It's a bit more like pricing artwork, which is another example of "not a cost-plus" system. Also, being more of a service than a product, the costs are much less material for medical care.


I think that's true to a certain extent, Jose, but if your treatment involves drugs--as almost all treatment does--there's a significant product cost involved.

The laissez-faire, let's see-what-the-market-will-bear approach works well for most things, but not for medical-related stuff. If we're talking cars, or clothing, or coffee, selling overpriced stuff to whoever's foolish enough to pay for it is fine. If people aren't willing to pay what you're charging, they can do without--no big deal.

But when the "sell-a-few-to-rich-people" business model trumps the "sell-a-lot-to-everyone" business model in the medical field, people die. The following examples of egregious price gouging, with life-and-death consequences, come to mind:

Remember Daraprim (a drug which formerly cost $1 per pill, was raised to $5,000 per pill overnight by Martin Shkreli, and then got "generously" reduced 50% to $750 in response to the bad PR)? People are still either paying $750 per pill for a drug that formerly cost $1 per pill, or doing without.

Remember the EpiPen (a.k.a. inexpensive, widely-available epinephrine, packaged in a patented injector to make its administration a no-brainer for non-medical personnel like schoolteachers who might need to administer it)? It cost $56.64 per dose in 2007, when Mylan purchased it from Merck. It now costs more than $600 per dose, although it costs only about $30 to produce. Mylan has responded to the resulting bad publicity not by lowering the price for everyone, but by issuing coupons to offset the costs for certain groups of consumers, which introduces its own set of problems.

And then there's Naloxone, which reverses the effects of opioid overdoses. Increased demand has resulted in a recent price increase for Naxolone injectors from $690 to $4,500, leading my local paramedics and firefighters to stop purchasing as many as they really need. That's how the market rights itself.

Before the U.S. Supreme Court ruled, 9-0, that human genes cannot be patented, the generally-regarded-as-best test for breast cancer and ovarian cancer genes had a list price close to $4,000 (as of this 2013 NYT piece), thanks to Myriad Genetic Laboratories' monopoly on it. I'm all for medical researchers being able to profit from the fruits of their labors, especially since that money can fund future breakthroughs, but come on.

Drug and medical equipment companies are in the business of making money for their shareholders, not saving lives.

Likewise, insurance companies are in the business of making money for their shareholders, not saving lives.

Insurance companies negotiate deals to reduce the price of drugs and equipment for certain groups of people, but that makes the prices higher for the people who can least afford them--i.e., the people who can't afford to buy insurance, and thus have to pay the list price out of pocket, or just do without. (Speaking of those who can least afford to pay for medical care, what genius thought of linking health insurance to employment, so that when people get too sick to work, and thus lose their income, they lose their medical insurance as well? But I digress.)

TL,DR: The evidence seems to suggest to me that laissez-faire capitalism really isn't the best way to provide medical care.

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Re: ACA Lives For Another Year

Postby Dark567 » Mon Mar 27, 2017 6:27 pm UTC

Zohar wrote:
Dark567 wrote:Besides, it's mostly irrelevant to my point that one of the reasons the US is so expensive is the lack of incentives anywhere in the process to control costs or do any sort of cost benefit based on how long you are expected to live. In most other countries insurance or the government would look at your appendectomy and say "hey, this is a young dude who is expected to live for another 50 years, totally worth 45k".


You have to keep in mind in most other countries an appendectomy would cost a lot less than 45K.
Well, yes(I noted this in the original reply to TGH). But I would also note that part of the reason it is higher in the US is because we don't do a cost-benefit calc like they do in most other countries. And sure, appendectomies are probably not directly pushed down by incentives from a cost-benefit system, but the economics of medical care has a lot of cost disease in it and between specialties, meaning the increasing use of cancer treatments that fail a cost-benefit analysis cause the cost of a cost-beneficial appendectomy to go up.
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Re: ACA Lives For Another Year

Postby cphite » Mon Mar 27, 2017 9:13 pm UTC

ObsessoMom wrote:TL,DR: The evidence seems to suggest to me that laissez-faire capitalism really isn't the best way to provide medical care.


Agreed.

The real problem is that we have a system that's trying to be "market based" but is almost completely prevented from acting like one. These ridiculous prices are due in very large part to a complete lack of market forces. These companies charge thousands of dollars for a pill because they can and the reason they can is because most consumers are completely isolated from the market. A market that was actually open wouldn't support these prices.

At any given hospital you have a chargemaster, which is basically a list of every service and item that they provide and what it costs. How they arrive at that cost depends on the item or service, but generally speaking they try to calculate the expected real cost as well as - and this is key - the expected number of patients who will actually pay. So basically, let's say you need an MRI and it costs you around $2,000 to get it done at your local hospital. Did it cost the hospital anything close to $2,000 to give you that MRI? Heck no. Not even remotely.

What they do, essentially, is figure out how much it costs to run the MRI for the year - the machine, the maintenance, the power, the people running it, and so forth - and they tally that up, then they divide it by the number of people they expect will get an MRI and actually pay for it. There are a number of reasons why people might not pay, but the point is they've calculated what they think they need to cover costs of everything plus whatever margin they believe they need, as well as some good 'ole fashioned guesswork and they arrive at some crazy number.

To make matters worse, the prices can change wildly depending on where you go. It might cost you $400 to get an MRI at an imaging lab, and $4,000 to get it done at a hospital. It's not necessarily that the hospital is being greedy; the MRI lab has teams of technicians who read MRI and not a whole lot else; the hospital is often paying people with much wider expertise, or they're paying doctors, or they're paying the guys from the MRI lab as consultants, etc.

As far as the market goes, most people have no inkling or even interest in what these things cost until after the fact; because the costs are almost completely hidden until after the fact. Someone in the hospital who needs an MRI doesn't shop around - they get the MRI and the cost is whatever the cost is. Market pressure is practically nil as far as cost is concerned.

And therein lies the problem. Hospitals and other providers charge whatever they can get away with, and insurance companies pay it. Which is fine for the insured people, but it pushes the costs to levels that are completely out of reach for most of the uninsured.

If you really want to control costs and make health care affordable for people, you have to start with the reimbursement structure. Simply mandating that people have insurance, or better insurance, does absolutely nothing towards that end. The ACA does make some attempts to mitigate costs, but not nearly enough to counter upward pressure that insurance itself creates just by virtue of existing.

Single payer is one solution - just put the government in charge of the cost structure and the payment. Another way might be to abandon the fee-based system and move towards a more holistic salary based system. I don't have a perfect solution.

But what I do know is that if we keep our fee based system and use insurance to fund it, there will always be people left behind.

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Re: ACA Lives For Another Year

Postby elasto » Mon Mar 27, 2017 9:33 pm UTC

cphite wrote:The real problem is that we have a system that's trying to be "market based" but is almost completely prevented from acting like one. These ridiculous prices are due in very large part to a complete lack of market forces. These companies charge thousands of dollars for a pill because they can and the reason they can is because most consumers are completely isolated from the market. A market that was actually open wouldn't support these prices.

It's not even that simple. If someone's having a heart attack they won't 'shop round' to see which hospital could save their life for the cheapest. (If anything, people might prefer to choose the most expensive assuming (rightly or wrongly) that they'd be the best and therefore give them the best chance of surviving... How can you put a price on your own life after all?)

Likewise, while a consumer can reasonably decide whether it's worth it for them to spend 10x as much on car A as car B, they absolutely can't make a value judgement on whether it's worth it to spend 10x as much on pill A as pill B for their illness. That's something only medical experts trawling through the medical trials can decide.

Transparency in pricing really wouldn't make much difference.

Healthcare is a broken marketplace from many different directions, and so is one of the few areas where government taking ownership actually does stand a good chance of doing a better job. And, indeed, I'd argue that the UK's NHS is but one example of many as to how it can work and work well.

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Re: ACA Lives For Another Year

Postby ucim » Tue Mar 28, 2017 2:58 am UTC

ObsessoMom wrote:I think that's true to a certain extent, Jose, but if your treatment involves drugs--as almost all treatment does--there's a significant product cost involved.
Yes, but a lot of the cost of that "product" is really the research that went into all the other drugs that didn't work out, and the research that showed that this one did. That's not really product.

ObsessoMom wrote:The laissez-faire, let's see-what-the-market-will-bear approach works well for most things, but not for medical-related stuff.
Agreed, to the extent that medical stuff is unplanned. Which the most important stuff is (unplanned). I'm not advocating a market based approach, I'm merely stating that that's the root of what we have, amplified and distorted by the fact that its need is usually unexpected and desperate. That's the whole point of insurance.

ObsessoMom wrote:The following examples of egregious price gouging...
... are pretty steambottle. They are examples of the fact that the need for medical care is unplanned and desperate.

ObsessoMom wrote:Drug and medical equipment companies are in the business of making money for their shareholders, not saving lives.
This can be said of any business. "Teachers are in business to pay for their SUVs, not to educate students." It's not "exactly" false, but it's not "exactly" true either. Big corporations are just better at being insensitive. But we need big corporations in order to actually do the things that enable doctors to save lives in the first place.

ObsessoMom wrote:...what genius thought of linking health insurance to employment,...
As I understand it, it was a way for employers to buy a service wholesale and get credit for giving it away (as compensation) at retail. It was a tax thing. It was the nose in the camel's tent.

ObsessoMom wrote:TL,DR: The evidence seems to suggest to me that laissez-faire capitalism really isn't the best way to provide medical care.
It certainly seems that way. But I wonder how things would have evolved if health insurance never did get a foothold. Sure, poor people would be less able to afford health care, but they are also less able to afford food and shelter, without which people also die. And there wouldn't be the huge distorting effect of the insurance market (which squeezes prices down for their policyholders, thus raising it for everyone else, leading (once critical mass is achieved) to a complete inversion of the incentives.

There's no going back. But suppose the same thing happened with food? And then with housing? And then with access to legal aid?

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Re: ACA Lives For Another Year

Postby The Great Hippo » Tue Mar 28, 2017 9:10 am UTC

ucim wrote:This can be said of any business. "Teachers are in business to pay for their SUVs, not to educate students." It's not "exactly" false, but it's not "exactly" true either. Big corporations are just better at being insensitive. But we need big corporations in order to actually do the things that enable doctors to save lives in the first place.
I'm not so sure? Removing the enormous financial injection that is corporations would slow down research, yeah -- but corporations are really only interested in marketable life-saving procedures. I'm not so certain that removing corporations from the picture -- and relying on tax-dollars to drive research into functional life-saving procedures -- wouldn't ultimately end up recouping whatever losses we took from the billion-zillion dollars pharmaceuticals are willing to throw around.

Added bonus: I wouldn't have to sit through any more Cialis commercials.

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Re: ACA Lives For Another Year

Postby elasto » Tue Mar 28, 2017 9:47 am UTC

ucim wrote:There's no going back. But suppose the same thing happened with food? And then with housing? And then with access to legal aid?

I think all a basic level of all three should be universally available and taxpayer funded myself.

TGH wrote:but corporations are really only interested in marketable life-saving procedures. I'm not so certain that removing corporations from the picture -- and relying on tax-dollars to drive research into functional life-saving procedures

I have a soft spot for bounty schemes; eg. whereby doctors identify a clinical need (for a new generation of antibiotics, say) and government pays out a bounty or bonus to whoever can bring something to market first.

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Re: ACA Lives For Another Year

Postby Zamfir » Tue Mar 28, 2017 10:31 am UTC

I have a soft spot for bounty schemes; eg. whereby doctors identify a clinical need (for a new generation of antibiotics, say) and government pays out a bounty or bonus to whoever can bring something to market first.

I see this proposal pop up once in a while, but is there much real-world experience in favour of it? The prizes and challenges that exist are mostly PR schemes. It's handing out modest grants to people working on the issue anyway, with a game element to attract media attention. Such schemes might have their place, but it's a large step from there to something that can replace pharmaceutical patents.

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Re: ACA Lives For Another Year

Postby elasto » Tue Mar 28, 2017 12:21 pm UTC

Honestly, I don't know. It's a compromise from the government just owning its own pharmaceutical research firm and directing it to come up with a new line of antibiotics (say).

Because today's mantra goes 'Private sector good! Government bad!' it's a backdoor way of achieving public service goals but keeping the private sector doing the legwork...

But, yeah, if the public will was there for it I'd be all for governments directly funding end-stage, goal-directed research and then owning the resulting patents.

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Re: ACA Lives For Another Year

Postby Sableagle » Tue Mar 28, 2017 12:27 pm UTC

It comes at a cost, though.
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Re: ACA Lives For Another Year

Postby ucim » Tue Mar 28, 2017 1:02 pm UTC

elasto wrote:I think all a basic level of all three should be universally available and taxpayer funded myself.
But this becomes subject to the same creep that led to the welfare state and the healthcare mess. No matter what level "basic" is set at, there is pressure to move it up, and opposing that pressure is just mean. Then exceptions are carved out, perverse incentives get baked in, and things get byzantine. Got a plan for stability?

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Re: ACA Lives For Another Year

Postby Zohar » Tue Mar 28, 2017 1:06 pm UTC

There are many countries that have had a stable universal healthcare system for years, I'm not sure why the US can't adopt those. Like, Israel's system isn't perfect (it's just one I know well) and it's much better and much more accessible.
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Re: ACA Lives For Another Year

Postby The Great Hippo » Tue Mar 28, 2017 1:21 pm UTC

ucim wrote:But this becomes subject to the same creep that led to the welfare state and the healthcare mess. No matter what level "basic" is set at, there is pressure to move it up, and opposing that pressure is just mean. Then exceptions are carved out, perverse incentives get baked in, and things get byzantine. Got a plan for stability?
I dunno; Canada certainly doesn't seem to be crumbling beneath the weight of a bloated, byzantine system.

I'm deeply skeptical to the idea that credible research will halt the moment we start restricting the rights of corporations to monetize it. But more than that: I'm deeply skeptical of the idea that the pros of capitalizing medicine somehow outweigh the cons in the first place. Yeah, we should do more cancer research; yeah, we need money to cure AIDs -- we always want medical providers to have access to better technology. But we also need a healthcare system that actually focuses on things like preventative care, affordable medicine, and increasing people's over-all quality of life.

And frankly -- beyond maybe how preventative care reduces the amount of insurance payouts -- those just aren't things you're going to get in the current system. I know we all want cutting edge medicine, but if the only way for us to get billions of dollars for cancer research is to support a healthcare system that shits on the poor, then maybe we need to re-examine our priorities.
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Re: ACA Lives For Another Year

Postby Liri » Tue Mar 28, 2017 1:23 pm UTC

Yeah, I don't see "welfare state" as having a negative connotation. Private health insurance is a fake idea. It's in the same vein as currency traders.
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Re: ACA Lives For Another Year

Postby elasto » Tue Mar 28, 2017 1:37 pm UTC

ucim wrote:But this becomes subject to the same creep that led to the welfare state and the healthcare mess. No matter what level "basic" is set at, there is pressure to move it up, and opposing that pressure is just mean. Then exceptions are carved out, perverse incentives get baked in, and things get byzantine. Got a plan for stability?

The NHS has existed for seven decades and, while it definitely hasn't escaped its share of austerity caused by the financial crash, I'd say overall it's highly stable. In particular there is a strong cross-party consensus based on near universal public support that it should remain much as it does right now.

In addition, as automation and AI take over the labour market through the coming decades, I think the level that 'basic' welfare is set at should increase over time - otherwise what's the point of it all? The economy is a human construct and as such exists to serve the people, not the other way around.

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Re: ACA Lives For Another Year

Postby Dark567 » Tue Mar 28, 2017 2:05 pm UTC

Zohar wrote:There are many countries that have had a stable universal healthcare system for years, I'm not sure why the US can't adopt those. Like, Israel's system isn't perfect (it's just one I know well) and it's much better and much more accessible.
Well. There is a ton of reasons, I list some but it is definitely not exhaustive.

  • Moving from the status quo is hard. Let's say the US moves to the NHS model and nationalizes providers and ditches most insurance. You now are having to lay off about a million workers of insurance companies and various hospital administrators in addition to pissing off millions of shareholders of these companies. In the long term it might be good, but in the short-term, it would be very economical painful. Nationalizing just the insurance companies(closer to Isreal's or Germany's system), or forcing them to be non-profit might make this less severe, but still faces some of the issues.
  • When we try certain plans countries do as a complement to our system, they often don't work out as well. HMOs(how Isreal handles insurance) didn't really provide the benefits it does in Isreal. Some of this is probably because it is just one in a whole cadre of options on how to get medical care in the US. Maybe if we adopted HMOs alone we'd start to see the benefits, or if we expanded Medicare or VA for all we'd start to look like how healthcare was covered in Austrailia or UK respectively. But we currently have some bits of all.
  • Most US citizens are actually pretty happy with their current health care plans(although not with the system as a whole). But when those two things come into conflict they often focus on their own plans rather than the system. Creating a huge status quo bias from the majority, even if they don't like the system as a whole. We see this with the ACA and the Cadillac tax, but also any attempts to remove the tax subsidies to employers from providing Healthcare(which is how the majority of working American's get health care) are treated with harsh antipathy. Of course, we would have to move away from this to get a universal system but Americans are skeptical of moving from their current employer care into a more general marketplace, which don't have a good reputation in the US(for mostly valid reasons).
  • The US is richer than most of the countries we are discussing, Healthcare is a consumption good that goes up faster than income. I.e. the richer you are the higher percentage of income you tend to spend on healthcare, unlike food where you tend to spend a lower amount as you go up in income. We'd expect costs in the US to be somewhat higher.
  • We have a consumer-driven culture where consumers get the final say. In the NHS examples I used in response to TGH, I discussed how many countries measure cost against remaining quality-adjusted life years to decide if some treatments are worth paying for. In the US this gets a lot of backlash. If you get insurance and it covers cancer, it should still cover cancer treatments when you are 80.
  • The US subsidizes the world somewhat on medical R&D. It is certainly not the only country doing R&D or anything(Isreal notably does a lot), but it is the one that does it by far the most and we pay for it.
    "In a study published Wednesday in the New England Journal of Medicine, researchers found the United States comprised 51 percent of global research spending, at $131 billion in 2007. But by 2012, that number dropped to $119 billion, or 45 percent of the world's biomedical research spending."
    Granted, it has been trending down.

  • Partisan politics. I don't think I even need to explain this.
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Re: ACA Lives For Another Year

Postby Zohar » Tue Mar 28, 2017 2:12 pm UTC

OK, I get what you're saying and of course it makes a lot of sense (though, the US isn't vastly richer than the UK, Canada, Germany, etc. Israel isn't a particularly poor country either). Of course, change would be difficult. My comment was mostly directed at ucim, who said these plans aren't sustainable on their own, and I think the fact they have been for many years.
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Re: ACA Lives For Another Year

Postby cphite » Tue Mar 28, 2017 3:04 pm UTC

elasto wrote:
cphite wrote:The real problem is that we have a system that's trying to be "market based" but is almost completely prevented from acting like one. These ridiculous prices are due in very large part to a complete lack of market forces. These companies charge thousands of dollars for a pill because they can and the reason they can is because most consumers are completely isolated from the market. A market that was actually open wouldn't support these prices.


It's not even that simple. If someone's having a heart attack they won't 'shop round' to see which hospital could save their life for the cheapest. (If anything, people might prefer to choose the most expensive assuming (rightly or wrongly) that they'd be the best and therefore give them the best chance of surviving... How can you put a price on your own life after all?)


Someone having a heart attack isn't going to shop around, but someone having scheduled surgery, or an MRI, or some other procedure absolutely could shop around. You don't have to be a medical expert to look at costs, success rates, and so forth; and those are things that you can discuss with your doctor, or some other medical professional.

Likewise, while a consumer can reasonably decide whether it's worth it for them to spend 10x as much on car A as car B, they absolutely can't make a value judgement on whether it's worth it to spend 10x as much on pill A as pill B for their illness. That's something only medical experts trawling through the medical trials can decide.


Again, with the help of their doctor or someone else with the proper training, people could at least have the option.

Transparency in pricing really wouldn't make much difference.


It absolutely does, and there is a real world example that demonstrates it: Corrective eye surgery. For two decades the cost for the consumer has trended downward even while average costs in the market have trended upward, in large part because such procedures were not typically covered by insurance, and customers were choosing based on cost. Further, as insurance companies have started covering this service, the downward trend has stalled or even reversed in the markets where they're covered.

When people consider cost, there is downward pressure on cost.

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Re: ACA Lives For Another Year

Postby Dark567 » Tue Mar 28, 2017 3:29 pm UTC

The Great Hippo wrote:I'm deeply skeptical to the idea that credible research will halt the moment we start restricting the rights of corporations to monetize it. But more than that: I'm deeply skeptical of the idea that the pros of capitalizing medicine somehow outweigh the cons in the first place. Yeah, we should do more cancer research; yeah, we need money to cure AIDs -- we always want medical providers to have access to better technology. But we also need a healthcare system that actually focuses on things like preventative care, affordable medicine, and increasing people's over-all quality of life.

And frankly -- beyond maybe how preventative care reduces the amount of insurance payouts -- those just aren't things you're going to get in the current system. I know we all want cutting edge medicine, but if the only way for us to get billions of dollars for cancer research is to support a healthcare system that shits on the poor, then maybe we need to re-examine our priorities.
I don't think all research will be stopped, but a lot could. The US spend roughly half of the world R&D on Medicine right now. Losing a big chunk of that will delay many life-saving medications. As far as preventative care(in the US sense), most countries don't do it as extensively as we do. It has mostly been found to be a waste of money which is why in a lot of countries you don't see things like annual physicals and the testing(and liability) culture we have in the US. In most of the other systems of the world, you only go to the doctor when something is already wrong not for preventative medicine(although there are a few exceptions like Pap smears and colonoscopies that are done every 3 instead of 1 year). The idea of US style preventative medicine majorly reducing payouts is a myth, in fact, it is mostly the opposite and an unneeded expense.
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Re: ACA Lives For Another Year

Postby elasto » Tue Mar 28, 2017 3:52 pm UTC

cphite wrote:It absolutely does, and there is a real world example that demonstrates it: Corrective eye surgery. For two decades the cost for the consumer has trended downward even while average costs in the market have trended upward, in large part because such procedures were not typically covered by insurance, and customers were choosing based on cost. Further, as insurance companies have started covering this service, the downward trend has stalled or even reversed in the markets where they're covered.

When people consider cost, there is downward pressure on cost.

That's elective surgery. Moreover, it has to compete with non-surgical alternatives. That is really no different to any normal market. If you've got the money you can buy it and if you don't you won't. The demand-supply curve is relatively normal.

It's totally different when it comes to illness or emergencies when the priority is having the best treatment rather than any kind of value-for-money consideration.
Last edited by elasto on Tue Mar 28, 2017 3:53 pm UTC, edited 1 time in total.

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Re: ACA Lives For Another Year

Postby eran_rathan » Tue Mar 28, 2017 3:53 pm UTC

Dark567 wrote:
  • Most US citizens are actually pretty happy with their current health care plans(although not with the system as a whole). But when those two things come into conflict they often focus on their own plans rather than the system.


Do you have a cite for this somewhere? I'm not seeing any, and (ancedote) nearly all of the people I know who don't have either Medicare or Tricare (i.e. the VA) absolutely despise their health insurance, but shrug and say "Well, its better than nothing."
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Re: ACA Lives For Another Year

Postby Dark567 » Tue Mar 28, 2017 4:01 pm UTC

eran_rathan wrote:
Dark567 wrote:
  • Most US citizens are actually pretty happy with their current health care plans(although not with the system as a whole). But when those two things come into conflict they often focus on their own plans rather than the system.


Do you have a cite for this somewhere? I'm not seeing any, and (ancedote) nearly all of the people I know who don't have either Medicare or Tricare (i.e. the VA) absolutely despise their health insurance, but shrug and say "Well, its better than nothing."


http://www.gallup.com/poll/7366/most-am ... ntent.aspx
http://www.gallup.com/poll/199220/ameri ... t-low.aspx

US HC SAT.png
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Re: ACA Lives For Another Year

Postby eran_rathan » Tue Mar 28, 2017 4:06 pm UTC

thanks.
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Re: ACA Lives For Another Year

Postby cphite » Tue Mar 28, 2017 4:41 pm UTC

elasto wrote:
cphite wrote:It absolutely does, and there is a real world example that demonstrates it: Corrective eye surgery. For two decades the cost for the consumer has trended downward even while average costs in the market have trended upward, in large part because such procedures were not typically covered by insurance, and customers were choosing based on cost. Further, as insurance companies have started covering this service, the downward trend has stalled or even reversed in the markets where they're covered.

When people consider cost, there is downward pressure on cost.

That's elective surgery. Moreover, it has to compete with non-surgical alternatives. That is really no different to any normal market. If you've got the money you can buy it and if you don't you won't. The demand-supply curve is relatively normal.

It's totally different when it comes to illness or emergencies when the priority is having the best treatment rather than any kind of value-for-money consideration.


Its not totally different.

A few years ago my wife had major surgery - not elective, it was something she needed. We researched several hospitals and surgeons; we looked at factors like success rates, recovery times, and costs. Insurance covered most of it but not everything. There were some very significant differences in terms of cost; and frankly the "best treatment" choices weren't necessarily the most expensive. We ended up at an excellent hospital with a great surgeon - and the cost was around the middle of the range we looked at.

Granted, there will always be emergencies and other cases where choices are limited, but there is no reason why quality care has to be an all or nothing, take what you get scenario.

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Re: ACA Lives For Another Year

Postby kalira » Tue Mar 28, 2017 7:21 pm UTC

eran_rathan wrote:... nearly all of the people I know who don't have either Medicare or Tricare (i.e. the VA) absolutely despise their health insurance, but shrug and say "Well, its better than nothing."


Not here to discuss insurance in detail, but I do want to clear this up. Tricare =/= VA. Two very separate programs.

Tricare is a health care program for active and retired members of the US Armed Forces and their families. It has a number of plans that you/your family choose from. Tricare Prime is, I believe, the most "popular" option -- it's basically an HMO.

VA health care is (basically) only for veterans (both retired and separated), and the veterans are grouped based on proof of service in war zone, proof of service-related injury/disability, etc into "priority groups" -- you don't get to choose a coverage level. People on VA health care don't have to do anything else to meet the ACA's coverage requirement, but VA health care *is not* health insurance.

A service member can be eligible for both, but they have different benefits, etc. Anyway, I'm not here to do an in-depth summary, so I've glossed over/probably missed a few things. As someone who knows a bunch of people who have used both Tricare and the VA, though, I can tell you a lot of them feel exactly the same frustrations as everyone else about their insurance/health care -- seriously, talk to any vet about how long it takes to get medical care from the VA. (Can't speak to Medicare, not knowing anyone who uses it.)

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Re: ACA Lives For Another Year

Postby elasto » Tue Mar 28, 2017 7:29 pm UTC

@cphite:

Yes, non-emergency surgery is somewhere where transparency is useful, but from what you describe it's already there. It sounds like you could already get all the information you needed to make a judgement.

I had to go through a similar exercise when my child was born since my wife was not entitled to free NHS care and we had no insurance, so we had to pay completely out of pocket.

It was an epidural followed by a cesarian birth with about 8 staff present followed by days in hospital. It cost about £3k which was perhaps a tenth of what it would have cost in the US...

Much love for the NHS...

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Re: ACA Lives For Another Year

Postby Mutex » Tue Mar 28, 2017 7:36 pm UTC

elasto wrote:I had to go through a similar exercise when my child was born since my wife was not entitled to free NHS care and we had no insurance, so we had to pay completely out of pocket.

It was an epidural followed by a cesarian birth with about 8 staff present followed by days in hospital. It cost about £3k which was perhaps a tenth of what it would have cost in the US...

At least....

https://www.theguardian.com/us-news/201 ... n-new-york
A British couple say they could be in for a $200,000 (£130,000) hospital bill, after traveling to New York City for a five-day vacation, only for their baby boy to be born 11 weeks premature.

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Re: ACA Lives For Another Year

Postby Sizik » Tue Mar 28, 2017 9:10 pm UTC

Mutex wrote:https://www.theguardian.com/us-news/201 ... n-new-york
A British couple say they could be in for a $200,000 (£130,000) hospital bill, after traveling to New York City for a five-day vacation, only for their baby boy to be born 11 weeks premature.


Any updates on that story?

Edit: Looks like their insurance covered it.
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Re: ACA Lives For Another Year

Postby Mutex » Tue Mar 28, 2017 9:24 pm UTC

Sizik wrote:
Mutex wrote:https://www.theguardian.com/us-news/201 ... n-new-york
A British couple say they could be in for a $200,000 (£130,000) hospital bill, after traveling to New York City for a five-day vacation, only for their baby boy to be born 11 weeks premature.


Any updates on that story?

Edit: Looks like their insurance covered it.

I was actually looking for a story I think was about a different couple, they didn't have travel insurance and ended up with a $1M bill. I found similar stories for an Australian couple and a Canadian couple though who ended up owing over $1M.

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Re: ACA Lives For Another Year

Postby Angua » Wed Mar 29, 2017 5:58 am UTC

To be fair, 11 weeks premie is going to cost more anyway. Not really comparable to a fullterm birth.
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Re: ACA Lives For Another Year

Postby Dark567 » Wed Mar 29, 2017 6:14 am UTC

Angua wrote:To be fair, 11 weeks premie is going to cost more anyway. Not really comparable to a fullterm birth.
Particularly when it looks like birth defects are involved(although I guess that premature, it is almost expected). Anyway, definitely not comparable to just having a baby in the US.
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