08-13-2012, 03:42 PM
Gordon, we're choosing between a "bad" and "maybe not so bad" for qute a few years already. The good ones are either not on the market or not marketable.
Maybe the main problem is with the buyers, and not the merchandise itself.
08-13-2012, 04:51 PM
I welcome a discussion of ideas and reasons why you think it will imporve the country. My opinion is that Obama and Biden have had 3 years and all they seem to do well is blame their predecessor. If either of them worked for me and pulled that crap I'd of fired them after the second year regardless the circumstances. I have yet to hear obama or Biden communicate a plana at all, let alone a sustainable one.
Originally Posted by PeteM
08-13-2012, 04:55 PM
I'd agree with your first point (not much impact for employers), but disagree with your second.
Originally Posted by jscpm
First thing, there aren't many small insurance companies left in the US. The top twenty five dominate the market (and also skim billions off the top). Note that many of the top 25 are named Blue Cross something or other. As just a personal point, when I got insurance for myself and my wife a decade or so ago, there was only one viable insurance option available. At that time I still played competitive soccer, quite healthy at 50 years old, and my wife much the same. It wasn't like all 25 big insurance companies were open to me; they'd carved up the nation into fiefdoms. What Obamacare and its provision of exchanges does is increase the number of viable alternatives, and likely reduce cost through this competition.
As for degradation of coverage for healthy people, the one time most healthy people will need outstanding medical attention is in an emergency room. Getting the clutter out of emergency rooms can only be a benefit for those in true need. In addition, now that the mandate has passed Supreme Court muster, there's much less ability to cherry pick an insurance pool that only includes healthy people and kicks sick people out. That's surely a plus for working people who might end up with something like cancer and who previously were likely to lose coverage. Your point about having nurses hand us pain relievers is probably right on track -- but isn't that what we'd want from a cost-effective health care system? Finally, the freedom employees will have to move to any job they want without losing their insurance, including creating their own business, is surely a plus for a free nation.
From the acted outrage being expressed about Obamacare you'd think that Martians have invaded and were about to kill off humanity. It's true the Affordable Care Act is hardly a cure for all or even most of what ails health care. Lots of reforms remain untouched. But, the slight impacts it will have are most likely, mostly positive. We'll still have the same doctors, doing the same job. What's new will be a bit tougher time for the largest insurance companies ripping us off, fewer people denied in time of need, fewer people getting a free ride because they don't want to buy insurance, and some experiments aimed at paying for better health outcomes. About the only real negative for today's conservatives will be that about ten percent more people may be covered. They see that as an extra 10% being paid by them, but somehow fail to see the 20% taken by insurance companies (5% of it earned), the condition of our emergency rooms, the numbers of people denied coverage when they most need it ("I'll never get sick") and so on.
08-13-2012, 06:01 PM
Pete, unfortunately, the tale of how beautiful our healthcare will become under Obama Dreamcare Act is just a tale. A bunch of slogans, the usual populist's rhetorics (as anything he has ever done starting well before he became the president).
The changes you mention (no pre-existing condition clause, longer coverage of dependent children, insurance for everyone, etc.) although very desirable, of course, will require enormous additional financing. Sure you can rob the wealthy and regulate the private insurance industry to death, but then let's call it is as it is: soviet-type socialism with all its charming consequences. The only thing that I find reasonable in this reform is the mandate.
All the talk about need for a reform was based on the fact that the current health care is becoming unaffordable. So you really believe they will DRAMATICALLY IMPROVE the health care delivery AND make it more affordable at the same time? You sound like a reasonable person. Do you really believe in those fairy tales? Those people are good at mismanaging and wasting your money, and you trust them with such vital decision as a health care reform?
They will butcher the existing system, and it'll become much worse than it is now. It will be a Medicaid for everyone (if you know what I mean). And there will be no way back. Please write it down, so that I could tell ten years down the road: "I warned you!" (if, God forbid, the Dreamcare won't be significantly readjusted).
Let them experiment on guinea pigs instead of the whole US population.
P.S. Note that I don't state that the republicans will necessarily be better. But, at least, they seem to be a bit more down to earth in respect to what tree the money grows on.
Also, if you ask me if I read the whole Obamacare reform, I have to admit that I didn't. Did anyone (including the author)? But if it looks like a duck, walks like a duck, etc., we can safely assume it is a duck.
Last edited by MichaelP; 08-13-2012 at 08:10 PM.
08-13-2012, 06:14 PM
Most all of Europe has better health care the we do,no?
08-13-2012, 06:22 PM
"The changes you mention (no pre-existing condition clause, longer coverage of dependent children, insurance for everyone, etc.) although very desirable, of course, will require enourmous additional financing."
Nonsense. The longer coverage of dependent children, up to age 26, has already been implemented. And no increase in costs for it.
In fact many insurance companies have already stated that even if the wingers repeal obamacare, they're going to keep that
feature in place.
THINK about it for a moment. The age group in question is 18 to 26 year olds. Those are very low risk for insurance companies, those
are the folks the actuarials WANT to have included in the mix.
The pre-existing clause is a give and take - the universal mandate means those with pre-existing conditions will have been paying for
insurance for years before their condition becomes 'pre-existing.' What the companies don't want is the guy who signs up when he
Insurance for everyone? That's another way of saying healthcare for everyone, and 'everyone' gets that right now. If you can't
afford insurance then you go to the ER and that's a VERY expensive way to deliver healthcare. We already HAVE that, the idea
is to do it better, cheaper.
Getting preventative care and care that does not depend on ER vistis in a crisis, that's gotta be cheaper then we have now.
08-13-2012, 06:28 PM
"...I'd be less worried that Romney has had field experience with mistakes..."
Ya got your wish there. He's made plenty of those. Took in lots of free taxpayer money
and where'd it all go? Don't ask, he's not saying.
What about the free taxpayer money Ryan took in, he wants to kill the same program
he used to get a leg up in life.
Any mistake those guys make, somebody else pays for. Not them. They wind up
with the dancing horse and the son of BOSS bailout.
08-13-2012, 07:02 PM
Sorry, Jim. It tells me that you're not buying insurance policies for your employees or yourself. The cost jumped right before this change was implemented.
Originally Posted by jim rozen
By the way, as soon as they started discussing government vs. insurance industry competition option, insurance companies raised their premiums dramatically. I can assure you that the same would happen to gas prices if the government starts talking about regulating gas industry income. This alone was a first bitter fruit of all the Obamacare efforts. And we will have to eat this fruit till something positive happens.
Indeed. But do you have an idea of how much more money the insurance companies (or any other payer) will have to spend to cover additional people with diabetes, psychiatric disorders, cancers, etc. ? Not just cover them, but to provide a service equal to the one an average Joe with an indemnity plan receives now. Are you sure it'll be be covered by a reasonably sized mandate money pool? I don't. Moreover, I'm sure it won't be even close to be enough.
"The pre-existing clause is a give and take - the universal mandate means those with pre-existing conditions will have been paying for
insurance for years before their condition becomes 'pre-existing.' What the companies don't want is the guy who signs up when he
If we leave the system largely as it is now, the mandate money may, hopefully, make cost more palatable for all of us (big maybe, but possible). But if we implement such dramatic changes as a sudden inflow of covered individuals many of whom are seriously sick, we'll be in a deep sh&*. We'll either have to pay way more than we pay now, or agree on a substandard level of care for everyone (or let's simply call it a care which is worse than we have now). In the best case scenario, it'll be an "HMO or Medicaid for everyone". Exactly what Canada, Israel and many other countries have now. It's nice and dandy if you don't know better. But it's a major step down if you compare it with what we have now or had before. We used to a certain level of medicine/care delivery and losing it will be very painful.
Completely agree. The only question is HOW to achieve this goal. I'm afraid nobody has the answer at this point. And until we have the answer, we cannot allow populists to experiment with our lives and lives of our children in order to get more votes today.
"If you can't afford insurance then you go to the ER and that's a VERY expensive way to deliver healthcare. We already HAVE that, the idea
is to do it better, cheaper".
Last edited by MichaelP; 08-13-2012 at 09:59 PM.
08-13-2012, 07:37 PM
Pete is right. You can't make something out of nothing. There is no magic bullet. For every benefit in Obamacare there is a corresponding harm that is going to happen, in many cases greater than the benefit from a dollar point of view.
For example, one thing Obamacare does is expand Medicaid eligibility, a lot. Right now poor and indigent people spend big bucks getting treated in hospitals under Medicaid. Obamacare will redefine "poor" so that a LOT more people will qualify for Medicaid. To pay for this expansion Obamacare is taking funding from Medicare, the senior citizen programs. What this means is that poor people will get more health access and old people will get less access. Its a tradeoff. You can't just magically say you are changing the income cutoff for a program and not pay for it.
Since Obamacare does not (and legally cannot) increase taxes, the only way to pay for it is by shuffling money around. You have winners and losers. In general EVERYONE will lose because the increased "care redistribution" will result in the system becoming even less efficient than it already is. Medicaid is by far the LEAST efficient big medical program we have right now, yet it will be expanded. Forcing insurers to accept people with expensive pre-existing conditions and pay the same rate as healthy people will have a huge negative impact on the overall quality of care for everybody.
08-13-2012, 07:59 PM
No, the US has far and away the best health care in the world. People fly from all over the world to the US if they need a difficult operation and they can afford it. Hospitals like Mass General, Childrens, Mt. Sinai, etc, have the most sophisticated and advanced care systems in the world and highest competency specialists. Europe is only better if you have a simple condition and don't want to pay anything and don't mind waiting. In all other situations the US is better. (BUT, see below for 3rd world countries)
Originally Posted by Greg White
To give you an idea how much better the US is, consider this: in the US there are 25 MRI machines per million persons. In countries like France and England there are 5 MRI machines per million persons--a huge difference. You will wait FIVE times longer in Europe to get an MRI, if you even qualify for an MRI (hard to do in Europe).
To get comparable care in Europe you have to pay double or triple what you would pay in the United States. Many advanced procedures like brain surgery and so forth don't even exist in Europe because their socialized medical systems cannot afford the tremendous cost of those procedures. Also, in Europe if you are poor you will not been seen by a specialist just as a matter of policy. For example, in France if you are poor you get what is called "Tier 1" coverage which does not include any costly, specialist procedures. So if you are poor and you get congestive heart failure in France you are a goner. In the US, Medicaid will pay for bypass surgery (at huge cost to tax payers).
Also, the wait times in Europe are crazy. Many Europeans who can afford it, fly to the US simply because in Europe specialists are booked literally years in advance.
CAVEAT: 3rd World Countries
In some cases in Europe, or in 3rd world countries you can get better care if it involves drugs because they have less regulation. The US is the drug nazi nation. Drugs are much cheaper and more accessible, even in Europe than they are here, so if you have a condition that can be fixed by a drug and not seeing a doctor, then you are better off in Europe or even Mexico or India.
08-13-2012, 08:15 PM
Michael, I think your concerns deserve a considered reply.
Originally Posted by MichaelP
1) The first thing I'd note is that we already have the world's most inefficient system, spending nearly 2x on health care per capita, while not covering all our people, and having worse health outcomes (for the average citizen) than a couple dozen other countries. So when you're worried that we'll "butcher the existing system" realize that it sorely needs at least a trim of the fat all around it. There's plenty of waste to trim, in order to cover another 10% or so of people.
2) On much the same note, having a great health care system, that covers more folks, at much lower costs doesn't require us to sort out if the Higg's boson or strings are the foundations of matter. A dozen other nations have already demonstrated this is possible. It's prior art. We just have to have the balls to adopt it. If we're really good, we can be first among them.
3) I really don't expect we'll dramatically improve health care and make it cheaper at the same time. What I do expect is the same improvement curve we're on (i.e. new medical discoveries), at a slightly bent cost curve (which has been escalating for decades), with a more trustworthy promise of health care for those who need it and who have insured themselves. Right now, families are being bankrupted, sick people are being denied coverage after years of paying for insurance, and our emergency rooms are filled due to our dysfunctional care system.
4) The number of additional Americans that will be covered is a bit in doubt, since the states will have a role in deciding this. Let's say it's 10% more people. We already have many of our poor kids and mothers on Medicaid. The newly insured will be a mix of college students who can't find jobs, people who have lost their jobs, some of the working poor who aren't covered by their jobs, some other of the poor, and a handful of the sick who were denied coverage. It's a mix of a lot of low risk, average risk, and a few high risk folks; with 10% more people likely to be around 10% more costs. Your question comes down to "HOW WILL WE COVER THIS HUGE INCREASE?" There are two pretty simple and pretty compelling answers. The first is that insurance companies are already taking 20% of health care dollars just to handle payments. It's proven that this job can and should be done for around 3-5% of health care dollars, so any step that breaks up the medical insurance oligopoly can take back 15-17% of health care dollars wasted by insurance companies and put it back to health care. The second answer is that requiring folks to participate in insurance, rather than free load if and when they need it, will generate significant new income. About 15% of our people are uninsured. I don't know the demographics well enough to know what broader coverage will mean, but I suspect it will generate at about 5% more.
5) As for trusting or not trusting the government, we actually have a track record to look at. First thing, we're only talking about the payments part of health insurance. I'll be seeing my same doctors and hospitals and you probably will, too. On one hand we have the insurance companies whose motivation is to deny coverage (180 degrees wrong for their "customers") and whose track record is that they keep 20+% of health care dollars for themselves. On the other hand we have government employees is to muddle through the day and whose track record with Medicare is to keep about 3% of health care dollars for themselves. So, tell me why I should trust the insurance companies??
6) As for experimenting on guinea pigs rather than the whole US population, I personally would have liked to have seen single payer (since it's an already up and running and proven). The way things have worked out, we'll have 50 experiments running on how to cut the costs of a payments system.
7) One of the biggest gains, not to be underestimated IMO, is that insurance will now go with the individual and not the company. It's hard to know how this will work out. My expectation is that we will free people to find or create better jobs, at a time when the old industries (e.g. good jobs on auto assembly lines and the like) are disappearing and we desperately need flexibility and creativity. I don't expect that our largest companies will change much with respect to insurance. Wal Mart will still suck. GE will still have coverage. But small companies, many of whom don't have insurance, will have to adapt. Whether they take the incentives in the plan to offer insurance or have their employees pay for their own insurance, the impact will eventually be to have employees more mindful of the costs and act more like consumers. Within the decade, I expect this will lead to some significant efficiencies.
We will still need to keep bending the cost curve. Letting insurance collectives bargain with pharma companies, and even buy from overseas sources, can help. Somewhat surprisingly (for a nation that thinks it has the best of everything in health care), the global market for everything from dental care in Mexico to triple bypass surgeries in India will bring costs down. If we manage to do publicly funded R&D right (i.e. start publicly targeting common ailments with cheap cures instead of privately targeting rare ailments with $100,000/year cures) that can also help. Simply rationalizing the system (much as we do in manufacturing) could dramatically cut costs.
Let me pick one example, MRI screening as suggested above. There's a fair amount of MRI equipment in my area, since every hospital and care center wants to say they have one. Many are old (which means long times inside them for patients and fuzzier results when it comes time to interpret them). None of them are utilized more than about 6 hours a day. Put MRI machines in a manufacturing scenario and you'd buy the most productive machines possible and run them from about 6am to 10pm. Costs per exam might be half (faster exams, more utilization). Is that cost reduction, with better results, and less patient time (but inconvenient scheduling and possibly a wait) better or worse?
08-13-2012, 09:08 PM
We don't buy health care - we buy health insurance. It is far more expensive than health care especially if you are very healthy. Health care is one of the overhead costs of the health insurance industry. Nobody is terribly interested in controlling costs because health insurance is all but mandated by law, and very soon will be mandated by law. With that much money involved you can be sure the government is going to be in the middle of it because the insurance lobby guarantees it. It is more about getting votes and bank rolled electioneering. The elephant in the room is the corrupting influence of a well-funded money machine that Washington feeds and nurtures for their own self-interests.
Originally Posted by PeteM
08-13-2012, 09:37 PM
I'm afraid we have completely different view on certain important things. These differences will hardy allow us to come to an agreement or find a mutually acceptable cure.
First of all, I do not buy the sentiments about how poor and inefficient our healthcare system is. Having a personal experience with several healthcare systems, I can assure you that what we have here is by far the best. Not the most inexpensive, not always perfect, but simply the best overall (for the country of this size and population). Yes, it does have things that need improvement: some of them related to finances, some are in the direct relationship with the imperfect legal system, etc. But nobody invented or has anything better at this time. Less expensive? Yes. But not better overall. This is not to say that the other civilized countries have bad medicine or untrained doctors. It's just that the overall accessibility of first class medical care is much better here. So, I don't buy this myth that they started shoving down our throats since recently. We can easily break the system, but fixing it instead of breaking would take considerably more effort and skills than what's on the table now.
Secondly, we have core differences in seeing the government as an efficient body to manage healthcare delivery (or almost anything else for that matter). In my firm opinion, the majority of the government endeavors is the classic example of the worst management fiascos possible. To me, being under government management means a total waste or resources by the most unconcerned, incompetent yet unpunishable beaurocrats who don't give a damn about anyone or anything. The government proves it over and over again, yet you and many other people find it possible even to discuss it. Have you ever tried to deal with the INS services, Welfare offices or Medicaid? I have, and I can tell you that it's difficult to find anybody more inefficient, unfriendly, uninterested, irresponsible or downright dumb than the "know nothing, fear nothing" individuals working there. Yes, there are exceptions, but they're quite rare. There is no competition there: as long as you got a chair to put your behind on, you're set for life.
I agree with you that more competition among insurance companies would be helpful (but not to the point at which we ruin the whole industry by idiotic regulations or unfair competition with Medicaid). It's nice to have a medical coverage attached to a person rather than to his employer. Etc., etc.... Just let's not throw the baby out with the bath water. The baby is not as ugly and sick as they want you to believe.
08-13-2012, 09:51 PM
I'd agree that private medical insurance is a "well funded money machine." And, like other powerful lobbies, it has surely bought influence. You can see it in the Republican votes against change, the Democratic accommodations to back away from both a public option and nick the insurance only a bit, and current insurance company spending on PAC money. The answer is surely to shake things up a bit and offer some real competition, which in slight measure the Affordable Healthcare Act does.
Originally Posted by dp
In railing against insurance, Dennis, I think you're maybe 20% right. That is, we all ought to have some of our own money at risk, so we make more careful choices as medical consumers and search for better/cheaper alternatives. That can easily be done and, in fact, is done in some insurance policies. When the states set up insurance exchanges, I hope we'll see more of this -- consumers making sane choices to lower their premiums and co-pays.
The other part is to have a truly transparent and open market for medical services, which we don't have. We don't know doctor's track records. We can't easily buy cheaper medicines from Canada. Artificial barriers to entry protect most every medical turf.
On the other hand, it's just crazy to think that everyone could or should have a $2 million nest egg set aside just in case they join the ranks of those who come down with a deadly-and-curable-but-costly-in-the-US disease. Spreading the risk is the right approach. Indeed, the modern corporation was created to do just that: spread and limit risk. I suspect you like the idea of corporate organization just fine; so why not insurance . . . assuming that 20% or so of consumer money at risk?
08-13-2012, 09:56 PM
Originally Posted by MichaelP
Spending is stable...
Taxes get cut below expendatures...revenue drops.
I don't think they have a clue.
Unless, of course, it was their GOAL to bankrupt the nation.
08-13-2012, 10:16 PM
To me, an open mind and the facts should be our great hope for resolving differences of opinion of every kind. The longer I've lived, the more I've seen how people cling to whatever dogma they've been taught. Sad, in a time when resolving differences could do us so much good. Imagine where we might be if a couple dozen Republicans had said to themselves "this Obama guy is pretty green, but we can work with him to get a better health care system, enact Simpson-Bowles, and inspire confidence in the economy." Didn't happen. Maybe couldn't happen due to hardening party dogmas.
Originally Posted by MichaelP
As to your points, first, I'll just note that for you to come to a personal knowledge that we have a better health care system than any other country, you would have had to live in them all. Even then, mere variability of experience would render your experience anecdotal. Having worked in a couple dozen countries and a couple years ago being told "you have maybe six months to live" I could add my counter anecdotes about the healthcare system. My own view is that our medical system is a bit like our Olympic medal count. In some areas we're the world's best. In others we're pretty laughable. Overall, we have much to be proud of, but we're no place close to 100% of the world's best practices. If we really want to know how we're doing, we have to look at the numbers. For example, some tiny little island country south of us seems to be producing better sprinters these days.
To your second point, we're not talking about healthcare delivery, which remains essentially unchanged under the Affordable Care Act. We're talking about payments. Pretty much the job that PayPal or Visa does: collect money, pay service providers, and check for fraud. The insurance industry keeps 20+% to do this. Medicare, PayPal, and other country systems keep 3-5%. You'll simply have to acquaint yourself with the facts of how cost-effectively our private insurers do this compared to Medicare, the VA, a dozen other countries, and even such benchmark candidates as PayPal and Visa do this to decide for yourself if you're dealing with facts or dogma.
You've clearly had bad luck for every one of your elected officials, police, fire, school teachers, route carriers, and all the armed services folks you've ever met to be a "total waste" and "unconcerned, incompetent . . . who don't give a damn about anyone or anything." Come to my neighborhood, the Bay Area. Turns out our natives wons about a third of the nation's medals this past Olympics and I'll introduce you to our great mail lady, some great teachers, a couple decent politicians (yeah, harder to find), a terrific fire chief and more.
What I've learned in the past decade or so is that on some topics (such as whether the earth is flat, the center of the universe, or around 6,000 years old) that the observable facts don't always make a dent in others' opinions.
08-13-2012, 10:17 PM
I think you don't get it. I've advocated for a health tax. We pay it, the government stays away from it. The surpluses go into a trust that earns interest. Too much surplus? They lower the tax the next year. Tax payers go to the doctor, the doctor sends the bill to the government, they pay it. No death squads, no turning people away, no prior condition penalty. Health insurance companies go out of business. Health lobbyists are illegal. Voters express their satisfaction in the voting booth. Easy.
Originally Posted by PeteM
Nothing else will work. Nothing else comes close.
08-13-2012, 10:29 PM
I prefer data to anecdotes...and as Tufte notes visual presentation is a powerful tool.
Originally Posted by PeteM
08-13-2012, 10:31 PM
08-13-2012, 10:35 PM
Damn, Miguel, both the facts and a compelling visual presentation. FWIW, I've bought every one (or at least the first three) of Tufte's books when they came out, but missed this graphic. Thanks for sharing it.