Where the ACA Should Go Next?
run75441: This is the first in a series of 3 posts written by Maggie Mahar discussing Medicare, what it covers, and what it lacks in coverage. Maggie touches on the Public Option and Medicare. I start to get edgy when people talk about the Public Option, Universal Coverage, Single Payor, Medicare-For-All, etc. as they do not really define it and who will control its funding. We have a Congress which is intent on cutting the PPACA/ACA/Obamacare, which many take offense to today, and leave us with far less. I am not so sure we can trust Congress and politics to insure our healthcare.
On Tue, Sep 9, 2014 at 1:47 PM, Dan <firstname.lastname@example.org> emailed:
Rortybomb, New Piece on Where the ACA Should Go Next Rorty touts the 2009 House Bill which calls for a Public Option and described here To improve ‘Obamacare,’ reconsider the original House bill
Maggie Mahar replies:
Originally I favored a public option, but in fact, at the time, no one really spelled out who would run the public option–or how it would be run.
One of the best things about the ACA is that lets both HHS and CMS make end-runs around Congress. I would never want a public option that was run by Congress.
Here is the comment I just posted in reply to the post “Where the ACA Should Go Next”
I would need to know far more about the public option—and how it would be different from Medicare– before voting for it.
Medicare is extraordinarily wasteful– 1/3 of Medicare dollars are squandered on unnecessary treatments that provide no benefit to the patient. Why? Because Congress is Medicare’s board of directors, and lobbyists representing various specialist’ groups, hospitals, device-makers and drug-makers control Congress.
Meanwhile, Medicare does not cover much needed care, ie. vision checks are just one example. This is why the vast majority of Medicare beneficiaries must buy separate private insurance (MediGap or Medicare Advantage) to supplement what medicare doesn’t cover.
Finally, I favor narrow networks. They keep costs down. The doctors and hospitals that are not included in the networks are those that refuse to negotiate prices. By excluding them we remind doctors and hospitals that we can no longer afford letting providers charge whatever they wish. No other developed nation allows doctors and hospitals to simply set prices.
As for the notion that a network might not include the specialist a patient needs to treat a particular disease, that’s simply not true. Under the ACA if a patient suffered from a rare disease and no doctor in the network was qualified to treat it, the patient can appeal at two levels and under the ACA, must get a speedy response.
Also keep this in mind: all of the medical research on cost and quality reveals that more expensive care is no better and often it is worse. Doctors and hospitals that are money-driven are likely to over-treat, putting their patients at risk without benefit.
Finally, I would favor a public option only if it were very different from Medicare. Ideally it would be run by an independent board and its decisions would not have to be approved by Congress. Instead, that board would use medical evidence to decide what to cover–and what not to cover.
Best, Maggie Mahar Health Beat Blog
The issue with narrow networks is that consumers get the shaft when they go to the hospital and some doctor appears that is not in network, unbeknownst to the patient such as assistants in the OR for example. Perhaps the hospital stay should be a bundled payment of all costs associated with the stay including physician fees. With the move towards hospitalists, it makes sense.
Otherwise people get charged a lot more by physicians they did not choose and never met while awake.
This happened to me in Sept 2012 with GB surgery when the anesthesiologist was out-of network and again in Dec 2012 after Open Heart (that one pissed me off [cholesterol is like 104, runner, backpacker, wing chun do student, etc])and the Radiologist was out of network. Insurance negotiated a rate since it was an emergency and not a planned event.
“Emergencies & Prior Authorization
When standard out-of-network coverage is not offered by a health plan, there are often two categories of exceptions: medical emergencies and prior authorization.
Definitions of medical emergencies can differ by state but they normally involve the sudden onset of severe medical symptoms.9 Under the Affordable Care Act, health plans cannot charge higher co-payments or co-insurance fees for medical care received from out-of-network emergency rooms.
With respect to prior authorization for out-of-network medical care, a healthcare provider would typically complete a formal request on behalf of a patient and submit it to the patient’s insurer. The insurer, however, is not obligated to approve the request and the insurer also has the general economic incentive to direct care towards its in-network healthcare providers where it has negotiated reimbursement rates.” https://www.healthpocket.com/healthcare-research/infostat/2016-out-of-network-coverage-obamacare#.WRXv3YWcGCg
United Healthcare talked to both providers and got a rate. “Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act. Insurance plans can’t require higher copayments or coinsurance if you get emergency care out-of-network and they cannot require prior approval either. All non-emergency care must be done in-network to be covered and may require prior approval.” https://obamacarefacts.com/questions/is-out-of-network-emergcy-care-covered/
There is a good answer here too: https://money.stackexchange.com/questions/18756/how-to-deal-with-involuntary-out-of-network-charges and it discusses bundled payments through the insurance company. The PPACA is moving in this direction.
Here is a way to appeal: http://www.patientadvocate.org/requests/publications/Guide-Appeals-Process.pdf through the ACA. I know some states have not done the Medicaid part of the ACA.
Another point, if it is an emergency; they have to accept normal reimbursement as shown in the one site I posted. There is due diligence for the odd cases which are always around
Maggie makes some important points, but this is America and the rules are made by the Congress. Who else is going to make the rules?
As for the doctors who won’t accept Medicare prices, I know one Dr who doesn’t like being told how to practice medicine. Turns out her prices were lower than the Medicare paid doctors.
My own experience with Medicare paid doctors was that they charged 4000 dollars for ten stitches and put heavy pressure on me to have an operation i did not need. When I complained to Medicare (It was their money) I was ignored and then shined-on.
I think I can think of some fixes, but it the end we have the Congress we vote for, and they make the rules. Of course if you think the “free market” (your money or your life) is the way to go, then we’ll get to see how that worked again.
“One of the best things about the ACA is that it lets both HHS and CMS make end-runs around Congress. I would never want a public option that was run by Congress.” It does not have to be Congress . . . they are not medically trained. This is one of the things I rail against when people say “Single Payor.” What doe that mean and what are the rules?
Note that one needs to treat a physician as a medical advisor. Today you can educate yourself on the web. When I doubt about an expensive proceedure get a second opinion, the Insurance companies are glad to pay for this if it reduces the number of expensive proceedures. But as the patient you have the right to say no,exercise this right. Just like unless the physician can justify using a non generic drug insist on generics, more because the period a drug is on patent can then be treated as a phase 4 trial of the drug with a much larger sample set. (Note the number of adds about bad reactions on TV)
That is correct. I was hospitalized >3 weeks with a blood disorder. Each day they would come a draw blood a couple of times a day till the veins in my left arm were destroyed by the end of the 2nd week. I finally stopped them and told them once per day and asked how long have to been doing this? I finally found a couple of them who could hit my veins. Some were angry at me. Tough . . .
I don’t understand your question or why it was directed at me.
All I was saying is that Congress makes the rules; don’t see how you can end-run around that, nor why it matters that Congress are not doctors.
One likes to think they would set up an oversight body composed of doctors… or something.
My own personal favorite single payer scheme is to run it like the states do highway construction: write the rules, then ask for bids from insurance companies to manage the day-to-day. then “inspect” the quality and honesty of the work and study outcomes toward revising rules.
supplement that with government run clinics or even government run full care hospitals and doctors in direct competition with the private sector, paid for by patients not the general tax-payer.
but the only insurance plan i can see working is like Medicare: pay a flat tax up to a cap that recognizes the principle that one day young healthy people will become old not-so-healthy so the premiums they pay while young should be expected to pay their costs when they are old.
It is a general question. You will see more answers to your thoughts the next few days. I am rehashing stuff said over the last 3 years.
Run, a single payer, or gov’t mandated and managed health care system that covers every person in the country will eventually get to the U.S. It’s only a matter of time.
You know this and so does everybody else. The only issue people really have is when .. .and this is also the reactionaries issue as well.
Why will this happen?
In 1883, 1884, & 1889 Bismarck implemented social sickness insurance, accident insurance, and Old Age & Disability Insurance laws in Germany.
It took another 45 or so years in reaction to the Great Depression for the US to follow suit.
It took another 30 or so years to implement Medicare foe the aged in the U.S. We’re slow on the uptake when it comes to following the European’s (we think we’re better).
It took another 50 years to the ACA. Despite the current reactionaries and lying, crazy man executive this too shall pass even if a set-back.
But the cat’s now out of the bag so in due course congress will mandate universal health care on a par with the best European nation’s systems.
You can bank on it with certainty. The only issue everybody has with it is WHEN. That applies to the reactionaries as well.. they know it’s coming and want to delay it as long as possible… but it will come anyway.. they know it. We know it.
It will require higher taxes, progressive taxes, but put more net money in people’s pockets over lifetime than they can get by another other method…. cost of health care will drop by single payer system or equivalent, taxes will increase to pay for it, but After Tax net available real income will increase because costs of health care and it’s adverse effects will be less than they can otherwise be. That’s precisely what the Europeans figured out already. More net money to spend over lifetime with better outcomes and better health and well being, fewer uncertainties and anxieties.
Having read the bill, the Manager’s Amendment, the Reconciliation, placing the PPACA into play in the US along with Maggie Mahar, investigating many different false claims by those who said it did not work or otherwise, and listened and argued with various pundits and elected political officials; I think by now I know how the sausage is made. I appreciate your comments; but, I believe we have a ways to go before single payer and/or other hybrid forms of it become more that just a slogan amongst those sipping latte at Starbucks.
Longtooth, I really do appreciate your comments. Thank you as they can be interesting at times.
After a long struggle the dreamers might well succeed in mandating universal coverage. But it will not be the promised utopia, and shortly thereafter people will purchase supplemental insurance The reactionary dreamers will take this supplemental insurance as a threat to their cherished single payer. But alas the courts will in time admit that government has no business preventing individuals from protecting their lives, self-preservation being the first rule of law and all that, And further in time so many people will have supplemental insurance to cover things the bloated and bureaucratic single payer system fails to provide that the majority will begin to wonder why they even have this universal coverage and if it would not be better to have a special program for the poor and aged while letting the young and healthy contract for what best meets their needs.
Single payer is a quest for unicorns. Rational people know there is no perfection, just an optimum outcome. But the dreamers look at the optimum and say it comes up short of perfection and should be discarded. Socialism is not inevitable, it may be inevitable that it be tried due to the human penchant for self deception, but it is also inevitable that it will come up short -not only of perfection but of less centrally controlled systems.
Ahh, the clairvoyant one arrives.
Neither Maggie or I would argue a two tiered system not being a possible end result or a good one either. Two tiered systems appear to work in many European countries providing healthcare at a much lower cost with evidenced based results outside of the service for fees healthcare we have in the US. So your initial statement may be correct and the issue is how to get there.
What could make getting to that type of healthcare fail is a bloated and self-serving legal and political Congress which has little interest in the true welfare of people who put it in office as displayed and led by attorneys such as yourself Mike. Maggie was pretty clear she does not have faith in Congress.
If you think you are going to hijack this thread, guess again.
All systems are centrally controlled, including markets. If you don’t understand that, you don’t understand nature.
Oh yeah, Mike, your dead wrong. The plutocratic system is a bloated failure and anything to make it more a failure you would want.
I think health care as infrastructure, you a business/profit plan. You are the globalist.
Please do not engage him. Thank you.
Not sure what a lot of the back and forth is about. Single payer clearly works in most advanced countries and while I do not diminish folks ripping off Medicare, it is much more efficient than any insurer with a lot less patient hassle. Plainly there is an issue with politicians being in control of a single payer system, but that means voters have to a) vote and b) vote smarter. We have seen what happens when they do not follow either rule, but what are the alternatives? The benevolent dictator or military junta is the real unicorn and even if government just provides the basics to everyone, it would improve health and reduce costs of the nation as a whole. Business would go for it just as social security ended the defined benefit pension, it would free them from competing for employees based on healthcare , reduce the tendency to discriminate against older and sicker workers and eliminate the free riders who obtain competitive advantage by not paying for their employees health insurance. It would free employees to bargain on other working conditions including wages. The only ones who lose other than insurance people and health care providers are young, healthy people who would be subsidizing the old and sick, but as pointed out young people become old people and they would not exist if it was not for people older than them. As a species we would be extinct if not for a degree of socialism. It is the free rider types who oppose socialism and I at least do not give them much credibility. Finally, the rich will always get better health care just as they get better food, houses, cars etc. that is just the way it is and is the reason that providing for the welfare of a nation’s citizens does not eliminate the motivation of most people to do better.
I agreed with Mike on two-tiered systems, they are in abundance with single payer being in the vast minority in places such as Taiwan, England, Canada, etc. A list of countries by what percentage is covered by public funding: https://en.wikipedia.org/wiki/List_of_countries_by_health_expenditure_covered_by_government . Here is Ezra Klein on “What Liberals Get Wrong About Single Payor.” https://www.washingtonpost.com/news/wonk/wp/2014/01/13/what-liberals-get-wrong-about-single-payer/?utm_term=.fef7e0608827 If we look at comparable countries to the US here is what Ezra had to say:
“There are few truly single-payer systems in the developed world. Canada has one, as does Taiwan. Most countries rely on many, many insurers. Germany, for instance, has more than 150 “sickness funds.” The Swiss and Dutch health systems look a lot like Obamacare’s health-insurance exchanges. In France, about 90 percent of citizens have supplementary health insurance. Sweden has moved from a single-payer system to one with private insurers. Yet all these countries pay vastly less for drugs, surgeries or doctor visits than Americans do.”
Here is what Uwe Reinhardt had to say:
“Single payer isn’t a panacea,” said Uwe Reinhardt, a health economist at Princeton University. “The magic they have is setting rates. But neither Medicare nor Canada has done anything innovative on the delivery side. Taiwan is trying a little bit but not a whole lot. By and large they just pay bills.” The limitations of single-payer systems became clear during the health-care debate, when the Congressional Budget Office projected that premiums for a public option would be higher than premiums for private insurance — unless a public option could avail itself of Medicare’s pricing power.”
“A health-care system that followed international best practices would direct the government to set rates. Or it would let insurers band together and negotiate rates collectively — a practice called ‘all-payor rate setting.’ But it wouldn’t need to eliminate private insurers. It’s good for consumers to have a choice of insurers, who have real incentives to innovate and devise better ways to keep customers healthy and costs down.”
In your response to Terry you cited Ezra Klein’s & Uwe Reinhardt’s opinions on what the U.S. options might be in future related providing affordable (assumedly) health care.
I find faulty logic with Ezra’s opinion that:
“But it wouldn’t need to eliminate private insurers. It’s good for consumers to have a choice of insurers, who have real incentives to innovate and devise better ways to keep customers healthy and costs down.”
Insurer’s provide zero health care or equipment for it or drugs. They do not innovate anything related to medical methods, medical science, equipment,or drugs. They have zero incentive to innovate any of these things at all, much less the means.
No health insurance company owns or controls any major medical equipment business, or start-up. They do not pay for medical research or medical / surgical innovations in any fashion, much less as a means of patenting it or profiting by it.
The automobile insurance industry doesn’t innovate automobile safety either or direct or incentivize automobile mfg’ers to;provide better safety features or safer vehicles. For example, MB innovated disk brakes, anti-locking brakes, crush zones to protect occupants in crashes… quite and totally independent of any auto insurance companies’ inputs or incentives. Bias ply and radial tires were innovated by tire mfg’ers by requests from innovating automobile company’s for “special” types of tires for their newest version high end vehicles. Insurance company’s had no role in these things what-so-ever.
So must then reject Ezra’s line of opinion that health insurance company’s have any incentive what-so-ever to affect innovations in medicine. They are simply middle-men profiting by packaging various medical procedures and options together at varying prices to increase the number of people who buy those packages since the more they purchasers the greater the profits the insurance company’s make.
It’s no different than automobile dealers who are the middle-men between the auto manufacturers and purchasers…. it’s frankly nothing more than a method of marketing the providers / mfg’ers products to the potential consumers of those products. The health insurance companies and automobile dealers take a cut for their product packaging services for the respective products the package.
Note for example how many states or municipalities have prevented Tesla from direct marketing to the customer… the packaging company’s are opposed because it leaves them out so they can’t take their cut.
Ezra’s opinion makes an elementary logical error — he implicitly assumes insurance company’s must provide the packaging, and then if that’s true then completion among those packaging business’s provides consumers with different options of which packages to chose. But that choice is only necessary if the packagers are the sole means by which consumers can purchase the heath care procedures and medicines they need.
In a universal health care system there’s no packaging required…since whatever health care service is needed is simply provided directly by the providers on demand/need… the costs are known, the profits established for any given set of procedures and health care required, and providers compete to obtain business or they cease being providers. The health insurance middle-men have no purpose or reason’detre to exist at all
It’s just like automobile dealers as packagers middle-men of automobile mfg’ers. The only reason they exist is because they front the costs of marketing and sales..It’s their dime for real-estate, sales offices & showrooms, and they’re the ones that provide the capital to purchase all the vehicles in bulk buy deals from the mfg’ers.
The effect is that it lays off much of the risk of variations in sales rates so that the mfg’ers have a fixed contract with the dealers to produce “n” vehicles per unit time . If the public stops buying or the economy takes a little hit the mfg’ers don’t have to give a shit in the short term of production and inventory for work in progress or supplier contra ts for deliveries because their contract with the dealers is already cut and a finished deal… for whatever time period into the future the dealers contract for.. by negotiations.
Like any volume of scale business, the more a dealer contracts tobuy from the mfg’er the lower the mfg’er’s price to them…. and if the dealer can insure a high rate of sales then their inventory costs are lower, profits higher, and turn-over of capital faster …. standard business 101.
In other words, the mfg’er lays off the sales risks to the dealers and the dealers take the deal because they’re willing to profit on the margins. Tesla simply says why bother …. Tesla will take the sales volume risk themselves, leaving out the middleman and thus Tesla can take the margins for their own profit.
The reason automobile dealers and state or local laws have been enacted to insure no direct sales (where this has been done) is because if mfg’ers decide to do direct sales for some proportion o sales it is able always undercut dealer’s margins and thus dealers profits and so as an institution they’re dead opposed of course. How the were able to get legislators to enact laws against direct auto seles by the mfg’ers is clearly a case of “you scratch my back and I’ll scratch yours behind the closed doors deals with legislators.
You are trying to make a discussion and distinction where little exists.
The perception is Europe has what America wants, a lower cost healthcare system. The misconception is the vast majority of European countries and for that matter global countries are single payor. That is false. These countries operate healthcare for citizens with commercial healthcare and public healthcare inputs. They do so successfully. So what is the difference? Commercial healthcare insurance is not the issue here and is a reflection of the healthcare industry. There is no error by Uwe, Atul, or Ezra. They hit it on the head. Kill the insurance, I do not care. The problem will still exist and we will still go down the same road. You missed the whole point as well as all the other single payor singers.
On your off topic automotive dalliance. US automotive still builds to a forecast regardless of what sales are to a point. Once they hit 60-90 days inventory they will slow production. Been that way forever with promises to change except they never do. It could be flexible with the variations of demand; but then, they would have to think and change things.
It is like Purchasing asking suppliers what the cost of a part is through the quoting process. They should already should know this, be able be able to ascertain this already, and what each element of the purchase brings to the table besides just price. Left over inventory is just sold off.
I appreciate your comments, thank you.
Thank you for clarifying. Perhaps, and I accept the criticism if my words didn’t match my meaning, what a single payer means is that gov’t set’s the prices… this is the case in Germany, France, Switerland, Sweden and the other major European States.
It’s called or referred to as “single payer” because the providers cannot negotiate prices in a market where the consumer is a fragmented and uninformed, but desperate purchaser of health care.
So the health care providers have one and only one primary customer… the gov’t. The gov’t is then in fact and in all practical meanings of the term a “single payer” purchaser simply because the gov’t acts directly for the consumer’s interest .. a total consumer’s union as it were…. all consumers are members of it so it encompasses 100% of purchasers.
The multiple insurers cited in Germany for example are minor “adders” to the single payer system’s standard services… they are not a significant part of prices for health care… unless the very wealthiest purchase private accommodations at the finest “kur” (spa) in Europe as their “adder” for example, and other very high end options for the top 1% or top 0.1% of incomes.
I’m also a little familiar with the current Swiss system, which is indeed more expensive for the upper middle and higher income brackets for the Swiss than most of the other European nations. But all necessary and primary care, including hip and knee replacements, recuperative therapy, drugs, MRI’s, CT scans, hospitalization, surgeries, even specialized university medical treatments (when a primary surgeon screws up something for example) are provided without additional costs, fees, or charges.
Furthermore this care is all scot freer for incomes below what I would guess (I have no precise number) is the lower 60% of incomes with a sliding scale going up from there and which sky-rockets above the upper 1% or so level. Gov’t sets all the prices for all care and drugs and divies up the charges in a highly progressive tax system..
So perhaps what people are discussing is something which is technically not a “single payer” system (i.e. Medicare like) , but which is for all practical and real intent’s and purposes a single payer system like Medicare.
I also note that you left out the very next very relevant part of Kliein’s piece when you quoted him. What you left out was:
“Yet all these countries pay vastly less for drugs, surgeries or doctor visits than Americans do.
Why? Because in every case the government sets prices for health-care services and products. Insurers in Switzerland don’t negotiate drug prizes with Pfizer. The Swiss government simply sets its drug prices and lets Pfizer decide whether to sell in Switzerland — or not.”
“The problem is that in the U.S. payers are fragmented while in other countries they are unified even if there are many insurers,”
In other words, the countries in Europe he’s referring to are “single payer systems” by all practical meanings of the term.
I am sure you dominate business meetings and I would be getting edgy to move on to something more substantive. This is not meant to be criticism and there are no grades at the end. Furthermore, I did not intentionally leave anything out. I do expect you to read the articles as I am not a librarian dispensing detailed C&P information willy-nilly. You are not a dumb person and I have watched you with others although I get bored half way through your comments and come back later to read after the noise settles.
Last time I looked, Germany’s public option portion paid 76% of all costs leaving 24% with the individuals unless an emergency. 24% is still a large percentage although not as big as the 54% not covered by the US. They pay a part in the scheme of things. Yes and nations do skew what you have to pay for healthcare.
Of course, Europe controls their healthcare costs whether it is socialized, single payor, or two-tiered. And no, they are not single payer/payor in the sense you and others would like to make them be. Medicare is not single payor either. It is Part A part B, Part D and Supplemental. If you do not get Supplemental you are subject to 20% of the cost left over from Part B. A person on Medicare with typical Tier 1 drugs can expect to pay ~$280.00/month. Put everyone one in the world on it and it will increase dramatically. Medicare is also subsidized the same as ESI by the gov.
I am going back to bed and sleep. I woke up at 4AM and can get a few more hours today. Thank you for your comments.
I think, my opinion, that the objective is for 100%of the residents of the nation to have complete health care at the lowest prices using a progressive tax system to insure that’s the case. The objective is not just “lower costs for health care”.
I believe I’m correct in saying this is the case in Germany, England, and France at least… nations that are comparable to the US in standards of living as among the most advanced nations on the globe.
I did a relatively complete analysis yesterday of a hypothetical system…. which was simply a private “pool” which was composed of 90% of the U..S residents paying for100% of all required health care for lifetime … using the actuarial lifetime of 80 years as my basis.
I assumed negotiated prices would drop by 40% relative of present total US heallh care expenditures (private and public), I assumed 20% of the public was too poor to pay that amortized annual price… so that it was absorbed by the other 80% (of 90%) of the residents. I assumed the other 10% were too choosy to belog to a “pool” and paid whatever the going rate was without the pool’s negotiated prices. It turned out that it cost less than $3000 / person per year for complete health care for life (actuarially 80 years)…. so when people actually died doesn’t affect the price.. whether at 98 after 20 years of nursing care or at 60 by falling off a ladder), no questions asked. But it required an upfront investment of a one time $7 trillion fro which interest income at 2%/annum invested in US treasuries paid all but 15% of the total lifetime costs .. whjich is how the price amortized annual price was ~$2850 per person per year. The $7 trillon plays forward to every succeeding generation during which the $7 trillion is paid back over a few generations. The only caveats were a) you couldn’t joint the pool after age 25, and once joined you can’t opt out (unless becoming anot resident and living in some other nation), and any child born or adopted to a member of the pool was automatically in the pool for life. In other words, within a generation all people would be in the pool (other than the 10% who never joined).
The basic and simple premise is that nobody knows or can even make an educated good guess how much health care they’ll need friom birth to death, or how old they’ll be when they die. They only know they’ll need the average +/- some uncertainty in total costs. But they don’t know which side of the average they’ll need, nor how much more or less than the average they’ll need.
But since without the pool they’ll pay 2/3’s more (+40%/60%) than those in the pool for whatever health care they do need they can never come in at end of life paying less than the pool members pay on a risk adjusted basis… so there’s no reasonable odds of them spending less than the average no matte what… unless they prefer to die young when they don’t have to… simply because they don’t want to pay the price for adequate care or can’t afford it.
Now there are a lot of ways to skin the cat and I’m sure my $7 trillion up front capital is not correct… there are far more financially viable means to do the same thing than I’m familiar with.
But just to put the $7 trillion in perspective … our current public total debt is $19 trillion and will be more by another trillion or two by the time the current administration and congress our Putting an additional $7 trillioin of debt which carries forward until it’s paid off over successive multiple generations.. and who cares how many since it’s all paying for most of everybody’s health care ad-infinitum into the future — simply by using it for 2% compounding interest income and then applying 80% of the interest income to present care costs… the other 20% used to pay down the debt over time or split it 10% & 10% to pay down and to replace it over time.
So the only real reson gov’t is needed at all is to guarantee the $7 trillion by the full faith and credit of gov’t, and to mandate the caveat that once joined you can’t opt out and that if born to a member you have no option to join the pool or not ..you’re automatically in for lifetime.
Now with a progressive tax system the $2850 per year/person can be spread more justly by income means.. or half of it can be spread more justly by means.
Note that this is in present dollars (nominal) and covers all present total health care applied to all residents in the U.S. and thus might be a bit more for more if 90% of the population is in the pool and they all receive the health care they need at all times from birth to death.
And then I thought .. gee whiz, 5% a year that the insurance company’s take in admin and another 3% in profits or more, is a huge chunk of change that could be better used to reduce the pool’s per person price/year, with no reductions in care or anything.
Oh, and with 90% all in, getting whatever care they need when the need it, then all they do is show their medical number … and the computer compiles the numbers, pays the providers accordingly and there’s almost no administrative costs.. just computer’s tallying the care provided who provided it, and who got the care. No allocations of who pays how much or what’s covered and what isn’t or billing services by providers and doctors or hospitals. No advertising cost overhead, or nearly none relative to present overhead by drug company’s, insurance providers .. all of which is unnecessary and primarily only used to determine profits and losses for tax purposes and deductions.
And since everybody’s in the pool (except 10%), and the pool negotiates prices then there’s no fraud to worry about either or if there is then the computer can detect it faster than investigators. and the fraud on the pool would have to be a collusion between member of the pool and a doctor or hospital… esily detected by out of whack relative to the distribution of all care provided by all doctors and all other member of the pool The pool member has no reason to commit the fraud since they get their care no matter what at rock bottom prices, so the only fraud would come from providers who when detected can be banned from practice, convicted, and imprisoned or forced to pay back what they defrauded from the pool plus a healthy fine.
I forgot to say that the only reason I did my hypothetical system is to find out from the very basic and simplest system of full care for 90% of all residents (NOT just Citizens) from birth to death why or even if gov’t or insurance company’s needed to be involved at all. Gov’t does need to be involved in a financial guarantee way and for mandating membership rules in the pool (with no opt outs), but insurance company’s are of zero value … no need whatsoever for them at all.
There was no statements made of government not being involved. It was never a question. Neither is your last statement valid as that was not posed as a question either. Thank you for your effort.
thanks for the analysis. i don’t know enough to guess how close to reality it actually comes, but it’s nice to have a place to start.
i would suggest that one kind of fraud you don’t seem to anticipate is providers providing more billable services than the patent really needs.
and then i’d ask if given the politics of America, in which “make the rich pay” is a losing proposition, what happens to your analysis if the people just pay a flat rate up to a cap for insurance, costs are controlled by the government — the only entity with the power and knowledge to do so, assuming they are honest — and the people understand that “the young and healthy” are in fact paying for their own future costs when they will no longer be young and likely have limited income.
i think the flat rate should answer the “progressive” need for those who have more to contribute to the costs of those who have less, while the cap should prevent the whole thing from becoming a “tax on the rich” which cannot pass.
you have addressed some of this, but perhaps not explicitly enough to be clear.
I only have a reasonable wag on the accuracy of my estimates, but they’re in a reasonable ball-park for purposes of realizing my objective … which was simply to figure out whether and/or to what degree a gov’t needs to be involved., would the pool’s payments be out of possible realms of reason, and whether there was any rational role for some kind of value add by insurance.
The wag’s basis is current total health care outlay in the US and a 40% reduction by power of pool’s 90% of customers is based on the average European difference per capita in health care costs relative to the US’s. So the wag can’t off by a lot. The numbers are therefore reasonable estimates, not absolutes
Certainly the “pool’ in my hypothetical can be substituted for a gov’t mandated “pool” but it doesn’t change the fundamental way a health care system without insurance company’s invoved would work.,. and indeed it just how the European nations structure health care as a mandated “pool” The “pool” negotiates prices with providers and drug company’s. The providers and drug company’s get to profit of course by only by reasonable levels if they want the pool’s business.
I don’t think a flat rate works though, and it certainly doesn’t work in Europe’s nations… and the are two reasons I think: A) the very wealthy don’t even need the pool’s price advantage.. to them the price is chump change, and B) health care, imo, in wealthy high standard of living, high resource rich nation is something like “equal rights”… a benefit of such wealth provided to the public… and in that sense the price paid should be relative to one’s means to pay after accounting for costs of essentials (housing, food, clothing, education, transportation) at some average rate…. say the median cost of those essentials. What’ left of income after that is expended is rough estimate of disposable income after essentials. Health care prices should then reflect a proportion of that disposable income. Obviously the wealthier 80% to 90% would pay proportionately more. Thatg’s jus thow I would begin to structure “fair” price for health care outlays// person, adjusted for family size, etc..
You have a point about fraud and methods of fraud…. I believe those can be covered without a lot of loss to the pool at least in terms of the overall objective. The present system does this legally anyway … doctors saying you need more x, or y, when you don’t or scheduling you for a return appointment at more frequent intervals than is even remotely necessary. A composite computer system operated by the “pool” would detect these outliers far easier and deal with them than is the case today.
I have no illusions about the politics in the US with “individualism’s” “rights and “freedoms” predominating the landscape .. it’s a fundamental flaw in the US heritage system of gov’t and elitism, and a favorite propaganda for the right. WTF does health care have to do with freedom and individual rights? It’s going to cost everybody about the same give or take a total unknown of variation over lifetime anyway.. so if “freedom” means gambling… do it in Las Vegas where it won’t have an effect on anybody else, or risk a new business venture.
I’m not sure what run’s point is .. he titled his post “Where the ACA should go next?” which was a question he posed. I’m just say where it should go next.. . not whether the current crop of politicians make that impossible.
If run wants to discuss or have discussion on why politics in present day makes a rational health care system impossible, or what can be done to change the nature of greed and right wing conservatism’s opposition to social welfare systems in general, health care being just one of all the ones’ they’re opposed to, then that’s’ fine, but there’s no rational discussion possible dealing with irrational foundations for things.
My point is that you have to know where you want to go before you can begin to chart the path of how to get there considering all the obstacles you will encounter along the way. What most seem to be doing is simply trying to figure out how to get around an obstacle in the present but have no idea where they’re trying to go… just getting past that obstacle seems to be their objective.
What’s politically possible and feasible changes as people become more aware of what can be without problems and more benefits to all… to wit: SS, Medicare, Civil Rights, women’s vote, LGBT rights. 8 hour work day, 40 hour week with time & a half for OT, putting a man on the moon and returning him/them safely… etc., etc. etc.
Like I said universal low priced / cost excellent full and complete lifetime health care is just a matter of time before it occurs. What we really need to do is know precisely what our objective is and how it will work rationally and justly. Then you start selling it as a real potential… telling it like it is…. health insurance co. will cease to exist in any significant cost factor form, for example.. so they’re an obvious present obstacle to be dealt with, etc.
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