Reforming health care by moving away from socialism, not closer to it: First in a series. Smash the monopoly!

[ryevermouthbitters]

One of the most important ways to make health care affordable for more people is to lower the costs. Doing so moves health care into the realm of the affordable without subsidies and simultaneously gives more choices to consumers of health care rather than less.

That is, if lowering costs is done the right way. Not through pricing mandates, but through competition. So the first step is to smash the government-encouraged (or even required) monopoly of MDs as basic health care providers.

Since 2000, there have been opened about 1800 retail health-care facilities, primarily in five states, which are attached to retail pharmacies and which are attended by nurse practitioners. You don't make an appointment and get told to come in 6 weeks here like you do with a doctor's office. You just walk in like you do to a Rite Aid. NP checks you out; if what you have falls within their baliwick s/he prescribes a course of treatment (including prescription meds if necessary) and you walk out. Else, they refer you to a doctor or even a hospital if necessary.

The results of the first long-term studies of them are in. For the studied conditions, retail health clinics provide every bit as good care as a doctor and at a significant discount to a doctor's prices. (http://www.annals.org/cgi/content/abstract/151/5/321) Prices were much much lower and quality of service was much higher than in emergency rooms, which is where all too many of the currently uninsured (and the insured for that matter) get their primary care. And after less than a decade of existence and despite significant regulatory barriers to retail health centers, over a quarter of the county lives within a ten-minute drive of a retail health clinic (http://www.annals.org/cgi/content/abstract/151/5/315).

The problem with health care is not that the government is not involved enough, it's that it is too involved. Anyone who thinks that the health care proposals now on the table will lower costs or improve quality should live in government housing for a few years. The answer is mostly less government, not more.

That said, next up will be an area where the government should do more: first-dollar deduction of qualifying health care costs.

[blank]

You could also look into why meds in the US cost between 10 to 100 times more than anywhere else in the world.

[ryevermouthbitters]

You could also look into why meds in the US cost between 10 to 100 times more than anywhere else in the world.Shush! That's number three in the series.

[SmartAleq]

While we're looking at lower cost health care alternatives, midwives cost a whole lot less than hospital deliveries, with excellent outcomes and much lower rates of unnecessary interventions and C-sections. Hospital deliveries of normal presentations without gestational complications are not cost effective, nor are they conducive to fixing up that pesky infant mortality issue we're fighting.

[WednesdayAddams]

Or how about we smash the monopoly that health insurances have?

We have already cut costs to the consumer to the bone. Insurance companies decide how those cuts are implemented. Speaking as someone who has been in health care on both the insurance and the medical service side, if we make any more cuts in cost, it will directly and dangerously affect patient care.

Follow the money. It isn't going to the doctors. Insurance companies are spending a million dollars a day to combat the public option. Where is that money coming from?

[Victor Frankenstein]

While we're looking at lower cost health care alternatives, midwives cost a whole lot less than hospital deliveries, with excellent outcomes and much lower rates of unnecessary interventions and C-sections. Hospital deliveries of normal presentations without gestational complications are not cost effective, nor are they conducive to fixing up that pesky infant mortality issue we're fighting.

For what it is worth to the discussion at hand..

My wife is a nurse and did many years in Labour/Delivery. When we lived in Seaside OR, the OBGYN doctor was planning on leaving the hospital and opening her own office with my wife. Together they would focus on more natural birthing methods, less surgical interventions, etc. The births would take place in their office.

Now, this doctor was well received and had a very good record in high risk births. She was pleasant to speak with, had a good bedside manner, etc. She was someone you wanted in the medical field working with people. She was tired of the hospital politics and decided it would be better to do her own thing.

After a deal of time planning, counting costs, etc, the plan fell through. They could not afford the malpractice insurance.

At the end of the day the doctor left the hospital and ended up being the county coroner/medical examiner.

In this case, the public lost out on two highly capable medical professionals providing a more natural and healthy birthing method based solely on the high cost of doctors getting malpractice insurance.

[Panacea]

I am in favor of nurse practitioners and midwives. I would have chosen a midwife for my two pregnancies but could not find any.

I also agree with Marissa - the insurance side of medical care has become a grotesque caricature of its original purpose.

There is one disconnect within this whole business which I would like to see fixed; that is the separation of the consumer (patient) from the cost of care. People just don't know (or care) how much things cost since insurance picks up the tab.

Could it be that, if nurse practitioner clinics were more widespread, that people could afford to pay for their own basic care? I'd like a model where the first, oh, $5,000 of medical care was on me; then I'd be able to afford an insurance policy for things over that amount.

[Stupid Sexy Flanders]

You know, rule #1 in any health care debate should be: you can't use the word socialism.

[ryevermouthbitters]

While we're looking at lower cost health care alternatives, midwives cost a whole lot less than hospital deliveries, with excellent outcomes and much lower rates of unnecessary interventions and C-sections. Hospital deliveries of normal presentations without gestational complications are not cost effective, nor are they conducive to fixing up that pesky infant mortality issue we're fighting.This is absolutely an outstanding example of what needs to be happen. Less regulation, or at least smart regulation which allows the expansion of consumer choices.

Marissa, the health insurer oligopoly will be an entire separate part of the series. Not sure when I'll get to it, but parts of it will be addressed in part two, about first-dollar deduction so I won't be able to put it off too far without seeming like I'm avoiding it.

7, I also haven't decided on a number for the part on liability reform.

NinetyWt, your preference will be such a running theme through this stuff that I'm not even sure it needs a separate number, but there will be a part about high-deductible plans in the part about the insurer oligopoly.

Stupid Sexy Flanders, with all due respect, people who deny that 'toward increasing socialism of an already highly socialized system' is the direction that the current administration is trying to take health care are exactly as smart at the little old ladies who have signs that say "keep the government out of my Medicare!" Exactly that smart. They just don't get made fun of as much because they're on TV instead of Youtube.

[SmartAleq]

There's been a concerted effort over time to not only marginalize and stigmatize midwives, but also to make the practice of midwifery illegal--when my daughter was born, some thirty odd years ago, it was illegal for midwives to practice in California and the process of finding and working with a midwife was eerily akin to making a complicated dope deal. The AMA has an incredibly strong lobby, and up until it became advantageous financially to allow nurse practitioners, physician's assistants and nurse midwives to practice they were absolutely ruthless about prosecuting those they felt were "practicing medicine without a license." In the case of childbirth, it makes about as much sense to prosecute the mother for the same crime, since having a baby is NOT a medical procedure, no matter how much the doctors would like to make it so.

As for the whole "socialism" label, in the context of the current debate the use should be discontinued because it's inflammatory and inaccurate--we, as a group, have elected to pool our resources to improve our infrastructure as a whole, making it possible to afford such things as a nationwide highway system, fire and police protection, the military, libraries, public education and other expensive items that no single person whose last name isn't "Gates," "Buffet" or (until recently) "Madoff" can possibly afford to pay for themselves. Plus, it's to our advantage to have all these things be as universally implemented to a uniform standard as is practical, which is much more difficult to do in an area like, say, rural Mississippi than in, say, urban Los Angeles, due to the highly disparate tax bases of these areas. As a society we're aware of these things, and trying to stigmatize health care (just another expensive infrastructure investment) as being categorically so different as to warrant the soubriquet "socialist" that we don't slap on our cops and teachers is just obfuscation and fear mongering. Use of the term needlessly emotionalizes a debate which should be conducted as a simple cost/benefit analysis--and when you look at it that way, offering an expansion of the already implemented, successful, cost effective (contrast Medicare's 3% administrative overhead figure to the 31% averaged by the private health insurers) and proven government funded public health care options (such as Medicare, Medicaid, the VA and Tri-Care) is an excellent spur to the private insurance sector to pull their goddamned socks up and do the job they're getting such an obscene amount of money to NOT do.

As it stands now, lack of readily accessible preventative and maintenance health care (which is dirt cheap, comparatively speaking) is being compensated for by extremely expensive emergency care that the hospital usually ends up footing the bill for, along with the 22% of all claims from nominally insured patients that are regularly disallowed by the insurance companies. This puts an unfair strain on already strapped medical providers, who have a legal obligation to treat everyone who comes in the door, at least enough for them to go out under their own power--which means that the expensive emergency treatment amounts to a million dollar bandaid that's completely wasted if the patient can't get followup care. This is a ridiculously inefficient use of time and resources which forces the hospitals to then charge everybody five grand for an aspirin trying to recoup those losses.

A robust public option also allows us to experiment with other forms of alternative care, such as doulas and lactation counselors to follow up with new moms and babies to give them a bit of respite care and encouragement, improving new baby care and bonding. Or visiting nurses to give respite care to family members of the chronically ill or elderly. Or visiting physical therapists--moving these services out of the umbrella of a hospital and allowing individual providers to contract their services directly keeps costs down and encourages entrepreneurship, and isn't that a fundamental goal in our society?

[Panacea]

One thing I'll add to your excellent post, SmartAleq, is the need for a shift towards hospice/pallative care for the dying rather than the endless efforts we now go through to keep some folks alive.

[SmartAleq]

I've been completely incensed at the ridiculousness of the Palins and Becks with their "death panel" bullshit--planning responsibly for end of life care is simply the last of a very long list of socially responsible actions every citizen should be expected to handle. Statistics show that 80% of all health care dollars are spent in the last two years of life, so it just makes sense to decide ahead of time just how much drastic intervention one is willing to go through. Financial sense, moral sense, common sense.

I also am liking the trend Europe and the UK are starting, with having monitoring machinery and the like delivered to homes so that sick people can be treated at home for a lower cost, better atmosphere and less exposure to resistant strains of bacteria found in hospitals. Nurses visit on the same schedule they would in the hospital, and if the monitors go off the hospital scrambles personnel to assist. For the majority of hospital visits, this would work swimmingly--not for ICU care, obviously, but for most other hospitalizations.

[Panacea]

My brother-in-law is an RN. Last winter he was working in the ICU somewhere in Manhattan. There was an ancient lady in there who was very, very ill; she was ready to pass on, but her son refused to listen to her; kept badgering the doctors to keep her alive, etc. My BIL was very upset by the whole thing; the lady kept begging him to let her die. :( It's insane, really.

I like your second proposition, although as you mentioned in your other post, there are places here in the Delta where there just aren't enough medical staff to make rounds like that. Seems like it would work well in more heavily populated areas of the country.

[SmartAleq]

I agree, the home hospital would really only work well in an urban setting.

Then again, in underserved rural areas a public option with reliable, quick reimbursement for services rendered, with a uniform reimbursement schedule and one simple online form to submit for payment would go a LONG way toward encouraging medical personnel to take a chance on opening up an office in an otherwise impoverished area. Tacking on a percentage boost in reimbursement to those who elect to operate in problematical areas would improve the general health and wellbeing of those rural communities and would do so in a totally free-market manner, too. Win!

[Stupid Sexy Flanders]

Stupid Sexy Flanders, with all due respect, people who deny that 'toward increasing socialism of an already highly socialized system' is the direction that the current administration is trying to take health care are exactly as smart at the little old ladies who have signs that say "keep the government out of my Medicare!" Exactly that smart. They just don't get made fun of as much because they're on TV instead of Youtube.

OK, but you should be obliged to:

a) distinguish between a democratic state with some "socialized" services and a socialist state

and

b) explain why a democratic state with some "socialized" services is such a bad thing, inclusive of your opinion about the army, the interstate highway system, and the national weather service

[WednesdayAddams]

Marissa, the health insurer oligopoly will be an entire separate part of the series. Not sure when I'll get to it, but parts of it will be addressed in part two, about first-dollar deduction so I won't be able to put it off too far without seeming like I'm avoiding it.

Alright, then. So long as you're addressing it.

[StateSmasher]

Why wouldn't you want to move more towards socialism?

[BJMoose]

* * *

The problem with health care is not that the government is not involved enough, it's that it is too involved. Anyone who thinks that the health care proposals now on the table will lower costs or improve quality should live in government housing for a few years. The answer is mostly less government, not more.
* * *


I'll take issue with this. The problem is not that government is too involved; it is that it sometimes is involved in ways that are counter-productive and sometimes is not involved in ways that would be productive. I think you see this, since in a later post you mention "smart regulation". Given all of the competing interests involved in health care, "no regulation" is simply impossible. In such an environment health care would quickly stratify into the haves, who would get care, and the have-nots, who would get nothing.

One big problem in any debate over the health care system is that a significant part of society has a knee-jerk reaction against anything involving the "gummint". But at some point, the government, and only the government, must act, since they alone have the power to lay down the rules that make systemic change happen.

"No regulation" isn't the solution. "Less regulation" isn't the solution. What we need is "smart regulation". (How we get that in a world where money talks and the rest of us are left sitting on the crapper, I haven't the foggiest!)

[ryevermouthbitters]

As for the whole "socialism" label, in the context of the current debate the use should be discontinued because it's inflammatory and inaccurate
It's supposed to be inflammatory and and it's entirely accurate, straw men about the cops or even examples of relatively successful socialism programs notwithstanding.

We'll get to why the public option is bad in a later thread. It appears that we're in broad agreement here on smashing the state-sponsored guild system which limits the supply of qualified health care.

I literally have no interest in arguing with people who think that "the army" is an example of socialism. None. Those people should not vote but rather just sit there and let their betters decide for them.

[ryevermouthbitters]

I'll take issue with this. The problem is not that government is too involved; it is that it sometimes is involved in ways that are counter-productive and sometimes is not involved in ways that would be productive. I think you see this, since in a later post you mention "smart regulation". Given all of the competing interests involved in health care, "no regulation" is simply impossible. In such an environment health care would quickly stratify into the haves, who would get care, and the have-nots, who would get nothing.I agree that "no regulation" is stupid. But in the case of health care, and in particular on the subject of this thread, the government is indeed too involved. They've set up a guild system that would make a middle-ages serfdom proud. Of course they did it not out of evil or even stupidity but rather out of "the best of intentions." At the time they were doing it modern medicine was in its infancy and there were lots of charlatans out there (including many who made it into the guild as doctors, of course, but still). But as with all government-enforced guild systems, the protected members of the guild coopted the regulation and restricted supply, ignorant of advances in technology, advances in sanitary knowledge, the reduction of many of the more severe reasons one might have to seek health care and (paradoxically) the increasing wealth which allowed more people to seek professional health care for conditions which they previously would have dealt with themselves or not at all.

One big problem in any debate over the health care system is that a significant part of society has a knee-jerk reaction against anything involving the "gummint". But at some point, the government, and only the government, must act, since they alone have the power to lay down the rules that make systemic change happen. We'll get to this later, but your premise is wrong. There's no government guarantee of housing and yet pretty much everybody who is not clinically insane or addicted to crack has a roof over their heads. The result of years and years of food aid, some good most terrible, is that our poor people are indeed not dying of malnutrition. They are dying of diabetes and other obesity-related diseases.

[SmartAleq]

I literally have no interest in arguing with people who think that "the army" is an example of socialism. None. Those people should not vote but rather just sit there and let their betters decide for them.

Well that's all dramatical and Lee Greenwood there, but it's pretty clear that whenever a society feels the need to move beyond a volunteer civilian militia and mount a professional, standing army it has moved its defense into the realm of a socialized general benefit. It's definitely something individuals can't supply for themselves and requires a pooling of resources to be able to initiate and maintain.

[ryevermouthbitters]

All right, but only once -- I won't be dragged into a debate on this because it is frankly too stupid a proposition. Much more stupid than they ones you're giving Clothahump shit about in the Pit.

The army and the police are not socialism, they are the only logical outgrowth of the State's claimed monopoly on violence. The responsibility of the State to protect its citizens and their property from violence from the outside is one of the very definitions of what a State is. Protecting those people and property from internal threats is only slightly newer, and again goes back to the fact that the State claims a monopoly on the use of violence. Without that claimed monopoly there's no telling how police forces would have evolved, though I do note that even with the State monopoly the rich use their excess resources to purchase much more protection than is often provided by the State. If you honestly believe that the Detroit Police and the gated communities which house the few rich people still willing to live in the city are somehow a "good" you shouldn't support health care reform of any kind -- the poor in this country have much, much better access to health care of similar quality to the rich than they have access to property and life protection similar to that of the rich.

[SmartAleq]

So then, where do Blackwater and Wackenhut fit into the equation? Civilian entities contracting to the government--and seriously, why do we need these guys when we have our own military? Is it just the same thinking that makes companies hire "temp" workers at three times the normal hourly rate and keep them for years because they think they're saving money on benefits?

Anyway, it seems the state isn't that invested in being the only badass mofos on the block if they're willing to pay a private corporation to do the really dirty work.

[liberaltarian]

The government's duty:

1. Put every US healthcare provider on notice that from such and such a date he is on a cash or credit card only basis with his patients.
2. Provide a forwarding address for all health complaints.
3. Dissolve.

[SoylentPopTart]

This is of course one of many ways the current system needs to be reformed. Costs need to be contained. We've talked in the past about people getting expensive treatments when it could have been done cheaper. Part of the problem is when people are hurt and/or sick they don't always think rationally like that.
My regular 'doctor' is a NP although she is attached to the local hospital system (which has it's advantages to her practice because she can order lab/rad work and referrals to specialists thru the hospital system as needed). I haven't found her rates to be so so cheap however they are cheap enough that my costs are manageable (after my HDHP insurance kicks in it's paltry amount). One of the challenges her practice faces is that they still have enormous administrative costs dealing with insurance companies. This is no different then a standard doctors office. There is also no real motivation for them to be that much cheaper. As it is, they have all the business they can handle. There's no shortage of sick people around.

[Zeener Diode]

...

One big problem in any debate over the health care system is that a significant part of society has a knee-jerk reaction against anything involving the "gummint". But at some point, the government, and only the government, must act, since they alone have the power to lay down the rules that make systemic change happen.

That's a natural reaction to the many instances of abuse we've seen done by elected and appointed government workers. Those people must be led, kicking and screaming, into the fold; Once in, they'll never want out.

...

We'll get to this later, but your premise is wrong. There's no government guarantee of housing and yet pretty much everybody who is not clinically insane or addicted to crack has a roof over their heads. The result of years and years of food aid, some good most terrible, is that our poor people are indeed not dying of malnutrition. They are dying of diabetes and other obesity-related diseases.

I must argue your analysis here, but I'm not about to derail this topic.

[Zeener Diode]

As for the "NP vs MD" argument: my current health plan offers no provisions for seeing anything less that a doctor for checkups and the like. If I want to see a nurse practitioner, it comes out of my pocket. I'd like to endorse this trend but I'm not about drop my coverage on basis of principle alone.

[SmartAleq]

Matt Taibbi argues in Rolling Stone (http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1) that the issues surrounding health care reform are reflective of a larger, equally broken system of government, and I have to say I'm hard pressed to counter his argument. Excellent read, by the way, well worth the time.

[John Corrado]

Matt Taibbi argues in Rolling Stone (http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1) that the issues surrounding health care reform are reflective of a larger, equally broken system of government, and I have to say I'm hard pressed to counter his argument. Excellent read, by the way, well worth the time.

Assuming that you like snotty, assholish rants designed to agree with your opinion, but if you don't like those, you don't read Rolling Stone anyways.

Taibbi makes excellent points assuming you agree with his central premise that government monopoly on health care is the best way to go. If you don't agree with that - or with the idea that doctors deserve to be paid less and are assholes for not embracing pay cuts - then he's pretty much pissing in the wind from the get - go.

[WednesdayAddams]

But John, we're not talking about a 'monopoly.' We're talking about another option. That does not preclude the private market from continuing in exactly the same manner it has for close to a century. No one has as yet satisfactorily explained to me how a public option = death knell of insurance companies.

[Muskrat Love]

While we're looking at lower cost health care alternatives, midwives cost a whole lot less than hospital deliveries, with excellent outcomes and much lower rates of unnecessary interventions and C-sections. Hospital deliveries of normal presentations without gestational complications are not cost effective, nor are they conducive to fixing up that pesky infant mortality issue we're fighting.

Agreed. All three of my wife's children were delivered by a midwife, and two of them at home. Price was not really a deciding factor (it was all covered by Medicare and it would have paid for a hospital delivery), my wife just doesn't like hospitals and feels like natural childbirth without complications is not a medical issue requiring the presence of a doctor.

It's insane how many babies are being delivered by c-section these days. The USA is rapidly catching up with South America in the percentage of births delivered by PCCS and the long term side-effects are becoming clearer.

[BJMoose]

I agree that "no regulation" is stupid. But in the case of health care, and in particular on the subject of this thread, the government is indeed too involved. They've set up a guild system that would make a middle-ages serfdom proud. Of course they did it not out of evil or even stupidity but rather out of "the best of intentions." At the time they were doing it modern medicine was in its infancy and there were lots of charlatans out there (including many who made it into the guild as doctors, of course, but still). But as with all government-enforced guild systems, the protected members of the guild coopted the regulation and restricted supply, ignorant of advances in technology, advances in sanitary knowledge, the reduction of many of the more severe reasons one might have to seek health care and (paradoxically) the increasing wealth which allowed more people to seek professional health care for conditions which they previously would have dealt with themselves or not at all.
* * *

Forgive my tardiness, but I skipped town for a couple of days to trade the joys of cyberspace for the joys of looking at microfilm of century-old newspapers.

OK, I think I've finally wrapped my mind around your thesis for this particular thread. It is that AMA-style medicine enjoys a government-protected or -induced monopoly.

Now, you haven't provided any specific evidence that this is the case. It probably is true to some extent, but I'm inclined to suspect that that was the AMA's doing, not the government's. They are just one of many professional organizations that have succeded in getting governments (usually state governments) to pass laws requiring people to use "licensed professionals" and the services they offer.


In any case, the AMA's grip isn't absolute. Osteopaths somehow survived the AMA's pogrom to stamp out all other forms of medical practice. Chiropractors are still mucking around on the fringes of medicine. Nurse practitioners and midwifery have been mentioned in this thread.

Which leads me to suspect that the actual cause of the present AMA bias lies not with the government but with the companies providing health insurance. It appears they have an absolute power to decide who they will and will not reimburse. To my knowledge, there is no federal law forcing the insurers to pay only AMA-style claims. Indeed, we find variation from company to company (and from plan to plan) in what sort of health care they will pay for.

So, it appears that the real problem here lies not with the government, but with the insurers. And that what is needed is positive government action forcing the insurance companies to cover alternative forms of medicine.*

(This analysis, of course, does not touch on Medicare and Medicaid, which is a whole different ball of fish, or kettle of wax, or something. . . .)

_____
* It occurs to me that this observation may, in a roundabout way, dovetail with your critique. Since AMA-approved medicine was virtually the only thing around when health insurance began its rise in the Sixties or whatever, the insurers simply went with the status quo and have been slow to change with the times. We may be describing the same elephant, just from different angles.

[John Corrado]

But John, we're not talking about a 'monopoly.' We're talking about another option. That does not preclude the private market from continuing in exactly the same manner it has for close to a century. No one has as yet satisfactorily explained to me how a public option = death knell of insurance companies.

Because the government will mandate that the public option not bias itself against pre-existing conditions (because even if they fail to force this upon the private insurers, it will be easy and politically popular to do on the public option) and subsidize the public option to ensure that lower income people can have easy and continuous access to it (see: gov't forcing Medicare payment to be less than regular insurance payments).

Likewise, the public option will never have to prove itself cost-effective or even cost-relevant; while Kaiser Permanente would go bankrupt if its operating costs were 10 times what they budgeted for, a government-provided public option would just ask for more money and get it, because no politician would want to be seen as wanting poor people to die. Also, because no current elected politician gives a good goddamn about not spending money.

So there will be a bunch of private insurance options, and then a government option that is easier to get into, cheaper to be part of, and offers the same services without having to worry about showing a profit or even avoiding a massive loss. If that's the case, why would anyone not jump right into the far cheaper, easier program? How do private insurance companies even begin to compete with a company that can just print more money when it needs it?

[WednesdayAddams]

For the better options? It is not a stipulation that the government will cover every little thing, any more than it's a stipulation that private insurances do.

On the record, Obama stated that the public option would not fund abortions. Sorry, then, I'll be continuing with my private coverage. It's a legal medical procedure available to women under several private insurers, therefore there should be NO reason for them to not be covered under the public plan other than the fact that a bunch of congressmen are scared by the hand wringers.

In addition, the vast majority of workers polled have stated they want to keep their private coverage. Also, the plan includes improvements on the private system so that pre-existing conditions are not the problem they are now. Plus, it will be necessary to qualify for the public option.

OTOH, if insurance companies were providing the care to their customers that they needed instead of padding their bottom lines, we wouldn't even be having this discussion.

[Giraffe]

Because the government will mandate that the public option not bias itself against pre-existing conditions (because even if they fail to force this upon the private insurers, it will be easy and politically popular to do on the public option) and subsidize the public option to ensure that lower income people can have easy and continuous access to it (see: gov't forcing Medicare payment to be less than regular insurance payments).
I don't understand this part of your argument. If the public option ignored pre-existing conditions but the private insurers weren't forced to, wouldn't that be nothing but a huge gain for private insurance? People with pre-existing conditions cost insurance companies money -- it seems like they'd be delighted if the government stepped up and insured them all at a loss. Given that public insurance will not have unlimited resources, this self-handicapping seems like it would make it easier for private insurance to compete for the business of the relatively healthy.

I'm currently somewhat neutral on the present plan. I'm hugely in favor of universal healthcare for basic stuff: preventative care, basic checkups, antibiotics, birth control, etc. The cost of keeping the poor and/or currently jobless healthy and out of the emergency room seems small compared with the alternative. But I think to have a working health care system for everything (government run or not) requires fixing the insane pseudo-economy that has sprung up between insurance companies and health care providers and led to prices for medical services bearing almost no relationship to reality. I don't think more privatization is the answer -- the free market is very good at optimizing efficiency to maximize profits. I don't see how to use those same mechanisms to maximize the healthiness of a population. If anything, profit-wise, there's a strong incentive not to cure or prevent any diseases -- treatment is far more profitable than prevention.

At the same time, I want to see rationality returned to health care costs and I'm not sure the current plan can do that.

[John Corrado]

OTOH, if insurance companies were providing the care to their customers that they needed instead of padding their bottom lines, we wouldn't even be having this discussion.

And what exactly is "padding their bottom lines"? Paying executives commesurate salaries? Paying profits to shareholders? Do the non-profit healthcare providers pad their bottom lines?

I don't understand this part of your argument. If the public option ignored pre-existing conditions but the private insurers weren't forced to, wouldn't that be nothing but a huge gain for private insurance? People with pre-existing conditions cost insurance companies money -- it seems like they'd be delighted if the government stepped up and insured them all at a loss. Given that public insurance will not have unlimited resources, this self-handicapping seems like it would make it easier for private insurance to compete for the business of the relatively healthy.

I suppose that's a possibility, but personally I seriously doubt that any politician is going to allow the public option to remain for too long a more expensive option than private healthcare.

And as for "not have unlimited resources" - have you seen the government spend over the last five years? Cutting taxes while funding massive boondoggles and pulling money out of nowhere for TARP and buying GM, along with a previous giant "this will save Medicare once and for all, we hope" couple hundred billion dollar influx - at what point do you actually think the resources that will be provided to health care will be limited? Especially when cutting resources becomes seen as dumping the sick into the streets to die - which is what Democrats were saying about Republicans who opposed the Medicare funding or supported Social Security privatization?

Since we're divulging opinions, I'm not necessarily against nationalizing healthcare. Do so has its downsides but also has its benefits, but I'd really like to see an honest discussion of it, and the public option just seems to me a way to backdoor to nationalized healthcare while avoiding the debate.

Then again, given that the current level of political discourse in this country seems to be "OBAMA = SOCIALIST HITLER" vs. "YOU WANT THE SICK TO DIE PAINFULLY AND HORRIBLY", maybe skipping the debate is best for all of us.

[WednesdayAddams]

Truly, you think health insurance companies are 'non profit'? Why would (http://www.thestreet.com/story/10494349/1/cigna-quarterly-profit-triples.html?puc=_tscrss) you think (http://pnhp.org/blog/2009/08/07/unitedhealthcare-1-health-tracker-and-2-winning-the-war/) something like that? Some plans are non-profit, but most are very firmly for.

As for padding bottom lines: insurance companies make a great deal of money on no-risk plans, also known as self-funded. The plan works like this: both employer and employee pay into a 'health savings account.' The plan administers it. There is a cap on total care for the year, only certain procedures are covered, there are no guarantees of payment, and the insurance company collects a fee for 'managing' the account. They aslo absorb any cash that is not spent at the end of the year.

It isn't an actual insurance plan and isn't called such but many large companies use them (like Cisco) because it's cheaper than risk based plans. Many times, employees aren't even aware they're enrolled in a self funded plan.

[John Corrado]

Truly, you think health insurance companies are 'non profit'? Why would (http://www.thestreet.com/story/10494349/1/cigna-quarterly-profit-triples.html?puc=_tscrss) you think (http://pnhp.org/blog/2009/08/07/unitedhealthcare-1-health-tracker-and-2-winning-the-war/) something like that? Some plans are non-profit, but most are very firmly for.

No, I think some healthcare providers are non-profit. Re-read what I wrote; my sentence was specifically asking whether you thought the subset of healthcare providers are non-profit are "padding their bottom lines"

As for whether some subset is non-profit, well I can li- oh, wait, you assert that yourself, so I have no idea why you're so outraged at my sentence.



As for padding bottom lines: insurance companies make a great deal of money on no-risk plans, also known as self-funded.

I'm still at a loss to understand how this is "padding bottom lines." I know plenty of people who use no-risk plans because they have few health costs and it's overall much cheaper as a plan when you're young and have few health costs, but need a "health plan" in order to see a doctor at all.

But let me be clearer about my question: what is the difference between "making a profit" and "padding the bottom line", other than the latter having a hint that the activity is unethical if not illegal? And if there is no difference, do you believe that it is unethical for health insurance companies to make any profits?

[WednesdayAddams]

As for whether some subset is non-profit, well I can li- oh, wait, you assert that yourself, so I have no idea why you're so outraged at my sentence.

Because I am a tard and mis-read your post. No, really. Not being snarky.

I'm still at a loss to understand how this is "padding bottom lines." I know plenty of people who use no-risk plans because they have few health costs and it's overall much cheaper as a plan when you're young and have few health costs, but need a "health plan" in order to see a doctor at all.

But let me be clearer about my question: what is the difference between "making a profit" and "padding the bottom line", other than the latter having a hint that the activity is unethical if not illegal? And if there is no difference, do you believe that it is unethical for health insurance companies to make any profits?

That is actually a good question. First, it's not exactly lying, but it is certainly discouraged by plans to employers to not clarify what 'self funded plan' means. Can the employee find out? Yes, assuming it occurs to them to ask. But it isn't information that is offered, you have to first know what it is to ask about and second know what the alternatives are. I think where it steps over the line is when you have Ut Review doctors being given bonuses for delaying and/or denying expensive treatments to patients based on a 'lack of medical necesity' when the necessity is clearly there, but it would aversely affect them financially. Then it's not merely about profit it's about padding every last cent possible, and yes, I find that ethically reprehensible.

I do not think it is unethical for a for-profit company to make said profit. I do find it as unethical as, say, the oil speculation that was proven to be going on not long ago to continually inflate the cost of even no-risk plans while continuing to reduce reasonable and customary reimbursement rates for physicians.

[BJMoose]

How do private insurance companies even begin to compete with a company that can just print more money when it needs it?

Well, the simple way would be to make folks who have private insurance available to them ineligible for the public plan. Would that work for you?


My own thought on "preexisting conditions": if everyone had to cover them, then it would be a wash. For every person they put off with a preexisting conditions clause, there may be another person they are stuck with because that person chooses not to change jobs so as not to suffer from the same clause with another insurer. (Well, OK, it probably isn't a zero-sum matter, but I suspect it is closer to it than the insurance companies think.)

[John Corrado]

Because I am a tard and mis-read your post. No, really. Not being snarky.

Thank you; I apologize for having responded with more snark than the situation warranted.


Yes, assuming it occurs to them to ask. But it isn't information that is offered, you have to first know what it is to ask about and second know what the alternatives are.

I would absolutely agree with that, but that leads us directly into a question of what should be done when a necessary situation is too complex for reasonable people to understand, which I think is part of the reason so much health care discussion is reduced to stupid, vapid slogans; but I also think that's a subject for an entirely different thread.

I state this as someone who does not understand his health plan in the slightest, and turns to his wife (who has taken college classes in understanding health insurance) to deal with this stuff whenever it comes up.

I think where it steps over the line is when you have Ut Review doctors being given bonuses for delaying and/or denying expensive treatments to patients based on a 'lack of medical necesity' when the necessity is clearly there, but it would aversely affect them financially. Then it's not merely about profit it's about padding every last cent possible, and yes, I find that ethically reprehensible.

I would agree that the giving of bonuses for denying treatment is absolutely stepping over the line.

But the reason this originally came up was that you stated

OTOH, if insurance companies were providing the care to their customers that they needed instead of padding their bottom lines, we wouldn't even be having this discussion.

which I strenuously disagree with. The "health crisis" has little to do with insurance companies and any assholish actions they've done, and far far far more to do with massive advances in science over the last fifty years that have moved a very large amount of ways to die into the "preventable" column. The problem is, the treatements and therapies to avoid dying from these now "preventable" things, along with the research to move event more things (like cancer or depression) into the "preventable" column is really freaking expensive.

Even insurance companies that are honest and don't pad their bottom line will need to deny necessary treatements or tests because they can't afford to consistently reimburse those treatements and tests. And most individuals can't turn around and pay for those things out of pocket because they can be outlandishly expensive. And some people would be unable to afford health insurance in the first place. And those two things are the reason we're talking about reforming health care.


Well, the simple way would be to make folks who have private insurance available to them ineligible for the public plan. Would that work for you?

I'm not sure, mostly because it depends upon what you mean by "available to them". Is it a matter of employment? If I'm employed and my job offers healthcare, no matter how shitty my job's plans are am I out of the public option? Is it a matter of income? If I make over a certain amount am I ineligible for public option? In which case, if I'm self-employed, I may not be able to get insurance at a reasonable rate so I still end up with no insurance.

[WednesdayAddams]

Thank you; I apologize for having responded with more snark than the situation warranted.
'Sokay. It takes a while to get used to after the Dope, but for the most part we really don't do the whole 'gotcha' semantics thing here. And I have no problem admitting when I'm wrong. It just happens so infrequently. ;)

I would absolutely agree with that, but that leads us directly into a question of what should be done when a necessary situation is too complex for reasonable people to understand, which I think is part of the reason so much health care discussion is reduced to stupid, vapid slogans; but I also think that's a subject for an entirely different thread.

I state this as someone who does not understand his health plan in the slightest, and turns to his wife (who has taken college classes in understanding health insurance) to deal with this stuff whenever it comes up.

And it pisses me off that people have to do so just to have a hope in hell of understanding it. I'm the go-to person for every member of my extended family whenever there's a hospitalization or surgery. It shouldn't be this hard, dammit. But insurance rules and regulations are written by lawyers, so...it's going to be that hard. I try to be as much of a patient advocate as I can, because trying to figure all this out while healthy is difficult enough. While suffering from a disease? Forget it.

I would agree that the giving of bonuses for denying treatment is absolutely stepping over the line.

But the reason this originally came up was that you stated

which I strenuously disagree with. The "health crisis" has little to do with insurance companies and any assholish actions they've done, and far far far more to do with massive advances in science over the last fifty years that have moved a very large amount of ways to die into the "preventable" column. The problem is, the treatements and therapies to avoid dying from these now "preventable" things, along with the research to move event more things (like cancer or depression) into the "preventable" column is really freaking expensive.

Even insurance companies that are honest and don't pad their bottom line will need to deny necessary treatments or tests because they can't afford to consistently reimburse those treatments and tests. And most individuals can't turn around and pay for those things out of pocket because they can be outlandishly expensive. And some people would be unable to afford health insurance in the first place. And those two things are the reason we're talking about reforming health care.

I absolutely agree. I'm willing to admit that more than a little of my opinion on this is confirmation bias. After working in this industry for as long as I have, it's difficult to not allow one's experiences color one's perceptions. I do think that the profits insurance companies have shown, even in the face of a huge economic downturn, point to fraud and abuse within the insurance system. Now, correlation may not imply causation, but it sure as hell stands there winking and pointing at it while jerking its head in causation's direction.

A big reason a lot of people inside the industry are pushing for insurance reform is due to the fact that for many decades, insurance companies have spent a LOT of money influencing public opinion. 'If your doctor didn't charge so much, your premiums wouldn't be so high.'

I'm sorry, but that isn't entirely true. Top specialists? Sure. But primary care physicians that I know and work with take home (after paying office space, employee wages and insurance, malpractice insurance, dues for privileges at various hospitals, continuing education classes, etc etc etc) about $75-$100K a year. Not really that much, all things considered. In addition, doctors cut their rates to about 40% of their usual and customary rates to accept an insurance company's contracted rates. I know of no other profession that does that. It isn't that those rates are not reasonable, because they're based on CMS' usual & customary fee schedule. It's that the insurance company is implying that becoming contracted means a large upturn in patients. That's true, but at the same time when you have to see 3 patients just to make the same amount, how much of a favor are you doing yourself?

All that said: I do not think insurance companies alone are the sole reason for the current healthcare mess any more than people living longer due to medical advances are. I think they are both contributing factors. But I also think the typical American worker is getting screwed in the process, and we need to find a way to make that stop. It's difficult to spend money and stimulate the economy other ways when you have $10K worth of medical debt to pay down.

[John Corrado]

There's no point in me quoting your post, Marissa, because I pretty much agree with you on all points. The current situation is way too confusing, way too complex, and there's too much misinformation on all sides. I absolutely agree that something needs to be done, and even as a "cut the government down" conservative, I'm not fully convinced that a single-payer system is a bad alternative, mostly because I don't know of any non-government-led alternatives that make any sense.

Which is why I'm reading this thread, to see if there's an alternative to our current situation that isn't handing the industry over to the government to run.