I used to be disgusted, and now I try to be amused.

[ThurgreedMarshall]

Originally Posted by sebastian_dangerfield

Actually, given 80% of plans are subsidized, if the premium increases significantly outstrip the new taxes used to cover the subsidies, and the GOP refuses to increase those taxes to adjust for those increases, doesn't that also put pressure on the program?

I honestly do not understand your position. (And to be honest, I haven't really read anything you've written as it relates to healthcare, so maybe that's on me.)

It seems to me that no matter how complicated providing adequate healthcare coverage is, there are a few simple truths.

1. The more people covered, the lower the premiums--this means the most efficient model is probably universal healthcare
2. The fact that we don't have universal healthcare means that insurance companies must make profits in order to provide insurance, which creates incentives for them to fuck as many people as possible--this is why, before the ACA, there were caps and preexisting condition bars, etc.
3. We either decide that we are a society (a Capitalist one at that, which necessarily means there are winners and losers) and provide assistance to those who require it, or we decide we are a libertarian wet dream in which the government provides protection to the rich and infrastructure for their businesses only

Now, maybe you're a libertarian when it comes to healthcare, which means you will continue to be angry that we provide insurance coverage as a society to those who would die in the streets without it. If that's the case, I guess when premiums increase (even if they increase at a lower rate than they did before the ACA was implemented) you will side with Republicans and continue throwing fits because you will have to pay for some of that.

But I really want to understand what you think the right approach is. Because, unless you choose one (universal healthcare) or the other (government completely out of the healthcare "business"), everything in the middle will have problems. The question is, do you have any interest at all in figuring out how to solve those problems or do you just want to bitch about your taxes?

TM

[ThurgreedMarshall]

This shit is a joke. Nunes is a fucking stooge. Ryan is complicit in all of this shit for sticking with him. There is absolutely zero integrity in the Republican House. I truly hope the Senate acts with some.

http://www.vox.com/policy-and-politi...etapping-obama

TM

[Pretty Little Flower]

Originally Posted by ThurgreedMarshall

This shit is a joke. Nunes is a fucking stooge. Ryan is complicit in all of this shit for sticking with him. There is absolutely zero integrity in the Republican House. I truly hope the Senate acts with some.

http://www.vox.com/policy-and-politi...etapping-obama

TM

It is a sick fucking joke. If it is a cover up, it is the most ridiculous dumb-ass cover up of all cover ups. If, as Sebastian insists, there is no there there, it is a bafflingly desperate attempt to make sure that nobody finds that out. It is a complete breakdown of governmental process and integrity. But Sebastian will scour the internet and find an economist to tell us that (although he has no idea whether what he is saying is true or not) it is at least possible that everything is going to be o.k. What a fucking relief.

The Daily Dose is a Mohawks tune from 1968, that has that nice raw early funk feel to it. "Pepsi":

https://www.youtube.com/watch?v=Hbwm8aNDgA0

[Greedy,Greedy,Greedy]

Originally Posted by ThurgreedMarshall

This shit is a joke. Nunes is a fucking stooge. Ryan is complicit in all of this shit for sticking with him. There is absolutely zero integrity in the Republican House. I truly hope the Senate acts with some.

http://www.vox.com/policy-and-politi...etapping-obama

TM

We have a cycle. McCarthyism, Nixon, Gingrich, Trump. Once a generation the Republican party goes on a rampage trying to loot stuff, clamp down on their opposition, and go all-in for the mega-corporatist state full of corruptions and emoluments, the old military-industrial complex. Then the Dems painfully slowly clean up the mess, and then it all happens again. Sometimes it comes from the McCarthys or Gingriches or Ryans in Congress. Sometimes it comes from a Nixon or Trump in the White House.

The frightening thing about today is that there is both Ryan and Trump at the same time. No Eisenhower balancing McCarthy, no Scott balancing Nixon or Clinton managing Gingrich.

[ThurgreedMarshall]

Originally Posted by Greedy,Greedy,Greedy

It certainly seems like this will end his political career for the time being. Maybe he's been promised something for playing the patsy? A nice sinecure from Alfabank? A six month gig as Arnold's apprentice?

New (admittedly completely unsubstantiated) theory is that Nunes actually engaged in the behavior he is currently supposed to be investigating while serving on Trump's transition team. This would explain a lot--like, "Dude, you need to shut this shit down because...well, take a look at this evidence that has your name all over it."

TM

[Greedy,Greedy,Greedy]

Originally Posted by Greedy,Greedy,Greedy

The areas I follow closest are taxes and foreign policy. Here's the thing on foreign policy, where I'm accustomed to finding plenty of Rs to agree with in dealing with one issue or another: his approach to every situation is just incredibly assinine. He's a clown who has assembled a clown car for a team. There are - count them - two people on his foreign policy team who have avoided self-inflicted wounds in the first 60 days - Haley, who has done nothing useful but at least hasn't screwed up badly, and Greenblatt, who may be the surprise star of the administration in part because he seems to admit his shortcomings and be willing to learn.

Tillerson, who ought to be at least competent, proved himself about the worst of them on the Asia trip.

I never believed I would say this, but I really miss Cheney and his neo-cons.

And now Haley is through the looking glass.

[sebastian_dangerfield]

I honestly do not understand your position. (And to be honest, I haven't really read anything you've written as it relates to healthcare, so maybe that's on me.)

You're better off for it. It's an argument where I think Ty, Adder and I debate past each other endlessly.

It seems to me that no matter how complicated providing adequate healthcare coverage is, there are a few simple truths.
[LIST=1][*]The more people covered, the lower the premiums--this means the most efficient model is probably universal healthcare

That is the most technically efficient model, but not for the reason cited. It's the most efficient because it's the simplest. One administrator and payer, versus any larger number of them, makes everything simpler and, from an admin perspective, cheaper.

[*]The fact that we don't have universal healthcare means that insurance companies must make profits in order to provide insurance, which creates incentives for them to fuck as many people as possible--this is why, before the ACA, there were caps and preexisting condition bars, etc.

I detest insurers, and even I can't say what they're doing is "fucking" anyone. They're avoiding risks. They previously had the right to do so. They no longer have that right. We could debate whether they should have that right, but that's not the issue of the moment.

The reason we do not have universal healthcare, I believe, is political. It has "socialist" connotations.

[*]We either decide that we are a society (a Capitalist one at that, which necessarily means there are winners and losers) and provide assistance to those who require it, or we decide we are a libertarian wet dream in which the government provides protection to the rich and infrastructure for their businesses only

We differ here. I'm not revisiting in agonizing detail the economic explanation behind it (which Ty and Adder will refute), but there is a way to give consumers and doctors more power, and to lower costs, by converting to true insurance. By that I mean preventative/elective care is on the consumer, chronic and catastrophic care is on the insurer. What health care "insurance" is right now is a TPA.

A conversion to true insurance would lower unit prices across the board, as removal of third party payers forces preventative/elective care providers to lower unit prices to affordable rates. (If they don't, their cash flow will crater quite quickly. Additionally, the cot inflating mechanisms necessarily introduced by a TPA system will be removed.)

The problem with this is it puts HC management at the preventative/elective level back in the hands of consumers. Most of the people we talk to about these sorts of issues contend, with good evidence, this is a recipe for disaster. They argue that people do better when insurers negotiate with providers, and they discount the argument that TPA structures inflate prices. But their real argument is a more depressing one... The average American cannot be trusted to handle his own health care.

They may be right. And here I indulge my inner Libertarian. If you earn enough that you cannot qualify for Medicaid, and still can't manage your own healthcare, you can't be helped. (This subsection of the population I suspect contains a lot of ardent Trump supporters. Live by the sword...)

Now, maybe you're a libertarian when it comes to healthcare, which means you will continue to be angry that we provide insurance coverage as a society to those who would die in the streets without it.

Not in the least. Medicaid should be retained to support those who truly cannot afford chronic and catastrophic care. It should also be available for women's reproductive health issues, as these are far more consequential and more severe than many that men will face.

If that's the case, I guess when premiums increase (even if they increase at a lower rate than they did before the ACA was implemented) you will side with Republicans and continue throwing fits because you will have to pay for some of that.

The ACA taxes are actually quite reasonable to me. I might do away with some of the more blunt ones and go with more surgical sin taxes (high fructose corn syrup, and other diabetes villains). But the tax element isn't a big driver of my gripe.

But I really want to understand what you think the right approach is. Because, unless you choose one (universal healthcare) or the other (government completely out of the healthcare "business"), everything in the middle will have problems. The question is, do you have any interest at all in figuring out how to solve those problems or do you just want to bitch about your taxes?

I really do conclude, based on some experience with health care debt (and other consumer debt), that TPAs are disasters from a cost-inflation and over-consumption perspective.

I understand that what I propose has little if any chance of political success. I doubt we can return to a true insurance system where people are responsible for their own preventative/elective costs, and providers are forced to charge a more honest market rate (rather than inflate the fuck out of unit prices to offset insurer aggregate discounts). But it's worth noting we've never tried such a thing. And it's worth noting such a solution trusts people to make decisions for themselves, while removing insurers entirely from the preventative/elective care market.

[Adder]

Originally Posted by sebastian_dangerfield

The reason we do not have universal healthcare, I believe, is political. It has "socialist" connotations.

That's part of it, but I happen to think a bigger part of it is that health "insurance" companies would go away and doctors would make less.

We differ here. I'm not revisiting in agonizing detail the economic explanation behind it (which Ty and Adder will refute), but there is a way to give consumers and doctors more power, and to lower costs, by converting to true insurance. By that I mean preventative/elective care is on the consumer, chronic and catastrophic care is on the insurer. What health care "insurance" is right now is a TPA.

Leaving aside the economics (which are at best incomplete), this is a recipe for people who can't afford it not getting care.

But their real argument is a more depressing one... The average American cannot be trusted to handle his own health care.

I don't know why this depresses you. Of course the average American cannot be trusted to handle his own health care.

[ThurgreedMarshall]

Originally Posted by sebastian_dangerfield

You're better off for it. It's an argument where I think Ty, Adder and I debate past each other endlessly.

That is the most technically efficient model, but not for the reason cited. It's the most efficient because it's the simplest. One administrator and payer, versus any larger number of them, makes everything simpler and, from an admin perspective, cheaper.

I detest insurers, and even I can't say what they're doing is "fucking" anyone. They're avoiding risks. They previously had the right to do so. They no longer have that right. We could debate whether they should have that right, but that's not the issue of the moment.

The reason we do not have universal healthcare, I believe, is political. It has "socialist" connotations.


We differ here. I'm not revisiting in agonizing detail the economic explanation behind it (which Ty and Adder will refute), but there is a way to give consumers and doctors more power, and to lower costs, by converting to true insurance. By that I mean preventative/elective care is on the consumer, chronic and catastrophic care is on the insurer. What health care "insurance" is right now is a TPA.

A conversion to true insurance would lower unit prices across the board, as removal of third party payers forces preventative/elective care providers to lower unit prices to affordable rates. (If they don't, their cash flow will crater quite quickly. Additionally, the cot inflating mechanisms necessarily introduced by a TPA system will be removed.)

The problem with this is it puts HC management at the preventative/elective level back in the hands of consumers. Most of the people we talk to about these sorts of issues contend, with good evidence, this is a recipe for disaster. They argue that people do better when insurers negotiate with providers, and they discount the argument that TPA structures inflate prices. But their real argument is a more depressing one... The average American cannot be trusted to handle his own health care.

They may be right. And here I indulge my inner Libertarian. If you earn enough that you cannot qualify for Medicaid, and still can't manage your own healthcare, you can't be helped. (This subsection of the population I suspect contains a lot of ardent Trump supporters. Live by the sword...)

Not in the least. Medicaid should be retained to support those who truly cannot afford chronic and catastrophic care. It should also be available for women's reproductive health issues, as these are far more consequential and more severe than many that men will face.

The ACA taxes are actually quite reasonable to me. I might do away with some of the more blunt ones and go with more surgical sin taxes (high fructose corn syrup, and other diabetes villains). But the tax element isn't a big driver of my gripe.

I really do conclude, based on some experience with health care debt (and other consumer debt), that TPAs are disasters from a cost-inflation and over-consumption perspective.

I understand that what I propose has little if any chance of political success.

Whether I agree with your approach and analysis is beside the point and all that's fine. But I'm wondering what your position is based on what is possible, politically.

Originally Posted by sebastian_dangerfield

I doubt we can return to a true insurance system where people are responsible for their own preventative/elective costs, and providers are forced to charge a more honest market rate (rather than inflate the fuck out of unit prices to offset insurer aggregate discounts). But it's worth noting we've never tried such a thing. And it's worth noting such a solution trusts people to make decisions for themselves, while removing insurers entirely from the preventative/elective care market.

I think the basis for this conclusion is flawed. This idea that insurers are offsetting negotiated discounted prices by inflating prices for those without insurance is just not how it works.

In fact, unless you're looking to increase market share by squeezing competitors out of the market (which ain't happening here) it makes no business sense whatsoever to provide services (or products) to one group below cost, at cost, or at a discount which is only supportable through price increases to others. I'm not sure why you think this is happening.

What is actually happening is that insurers negotiate prices down to an amount at which both parties benefit. Individuals are in a different boat. And since they have absolutely no negotiating power whatsoever, they're basically subject to contracts of adhesion and gouged. These are not offsets.

TM

[Adder]

Originally Posted by ThurgreedMarshall

In fact, unless you're looking to increase market share by squeezing competitors out of the market (which ain't happening here) it makes no business sense whatsoever to provide services (or products) to one group below cost, at cost, or at a discount which is only supportable through price increases to others. I'm not sure why you think this is happening.

He thinks insurance companies are paying more than a consumer would because providers quote inflated prices anticipating the discount they will have to offer payers.

Implicitely, he thinks providers have market power vis-a-vis payers, but would not vis-a-vis individual consumers, which is kind of weird.

[ThurgreedMarshall]

Originally Posted by Adder

He thinks insurance companies are paying more than a consumer would because providers quote inflated prices anticipating the discount they will have to offer payers.

Implicitely, he thinks providers have market power vis-a-vis payers, but would not vis-a-vis individual consumers, which is kind of weird.

I think that's the opposite of what he's saying (at least in his last post). But either way it makes no sense.

Just because the invoice that you see shows a deep discount because it reflects the negotiated price doesn't mean the non-discounted price is the real price. That bullshit invoice actually helps both the insurer and the provider. That fiction helps show the insured what a great job(!) the insurer has done to lower the price and it gives the provider legitimacy to just make up random, inflated prices they use to fuck the uninsured.

Also, this is a good article on how providers screw the uninsured and insured.: https://www.nytimes.com/2017/03/29/m...imes&smtyp=cur

TM

[Adder]

Originally Posted by ThurgreedMarshall

I think that's the opposite of what he's saying (at least in his last post).

It's not. He thinks consumers paying out of pocket will force providers to offer lower prices overall.

If he were just saying that the occassional sucker who pays list price out of pocket (i.e., the uninsured) won't get taken, there would be no disagreement. But that's a tiny fraction of purchasers (some of whom, of course, won't pay the whole thing anyway becaus they can't).

But he's actually saying that individual buyers will be able to get prices that are lower than the negotiated prices insurers pay.

[ThurgreedMarshall]

Originally Posted by Adder

It's not. He thinks consumers paying out of pocket will force providers to offer lower prices overall.

If he were just saying that the occassional sucker who pays list price out of pocket (i.e., the uninsured) won't get taken, there would be no disagreement. But that's a tiny fraction of purchasers (some of whom, of course, won't pay the whole thing anyway becaus they can't).

But he's actually saying that individual buyers will be able to get prices that are lower than the negotiated prices insurers pay.

?

Not saying you're wrong about what he's saying. But if that were the case, wouldn't insurers currently be paying more than individuals? That's like the opposite of any understanding of collective bargaining. Ever.

TM

[sebastian_dangerfield]

Originally Posted by ThurgreedMarshall

?

Not saying you're wrong about what he's saying. But if that were the case, wouldn't insurers currently be paying more than individuals? That's like the opposite of any understanding of collective bargaining. Ever.

TM

Providers inflate prices in significant part to offset bulk discounts demanded by insurers. This happens. No... Before you say it doesn't, It Does. Full stop.

This inflates prices generally across the board for preventative, catastrophic and chronic care. (Introduce cost inflation in one area and it will infect others.)

Remove insurers from the preventative and elective care markets and the providers will have to charge less. Individuals cannot pay anything close to sticker price.

Sure, preventative and elective care providers will try to keep prices high for a time, but they'll adjust quickly as their revenues sag because no one can afford them. This period of adjustment would be ugly for providers and consumers, but it would pass quickly and the market would set reasonable prices for individuals to purchase services directly.

Insurers would then be able to offer plans which covered exclusively catastrophic and chronic care, at much lower prices. This scenario would also introduce price transparency, which is a huge benefit to consumers (in terms of educating them and creating more competition to deliver value among providers) and is sorely lacking in the current marketplace.

I derived this view from concurrently managing portfolios of delinquent HC debt and credit card delinquencies. The impact of a TPA structure in both markets is much the same. When they aren't feeling the immediate impact of the purchase, the average American over-consumes and does not pay attention to price. The best way to create educated consumers of health care, who will pay more attention to theirs, and make better lifestyle choices, is to make them more directly involved in the transaction. A person paying for something out of pocket is a more prudent purchaser who will force providers to maximize value.

GGG will reflexively argue, "but preventative care isn't the problem!" He's right. It's not. The bigger costs are catastrophic and chronic care. But taking it away from insurers will allow for cheaper plans to cover those big costs, which benefit consumers. This at a minimum washes, if not significantly eclipses, any increased burden on the consumer from having to purchase preventative and elective care out of pocket. Also, the drop in unit prices for preventative care will bleed into chronic and catastrophic care, creating downward pressure on pricing in those areas.

The problem with all of this, however, is it requires the American to take control of his own health care. I think this is a very reasonable thing to ask. I frankly think a person who will not take the time to become an informed consumer deserves whatever bad turn he receives in the healthcare market, or any other market for that matter. That kind of laziness should not be coddled.

But, as Adder demonstrated, I am in the minority. The pragmatists, whose point I see, will argue persuasively that the common American is incapable of managing his own affairs. The do-gooder will assert that "smart folks" like us should set up systems to make the best decisions for these common people. I understand and appreciate both arguments, and I think they will rule the day. That's why I believe we will see single payer at some point. The end of all this will be a two tiered system like those in Europe.

[sebastian_dangerfield]

That's part of it, but I happen to think a bigger part of it is that health "insurance" companies would go away and doctors would make less.

Docs hate insurers, and they're not the ones robbing people blind. The administrators and executives are the unjustified cost. And they are robbing the industry blind, on both the provider and insurer side. Why? Because we've made HC a Byzantine system that allows these people to justify their existences and salaries.

You know what'd render a lot of those people unnecessary? A direct purchase system for preventative and elective care.

Leaving aside the economics (which are at best incomplete), this is a recipe for people who can't afford it not getting care.

I acknowledge my idea would cause certain people to not receive as much care as they do. But somebody's always going to lose in these things. I believe this is a small number of people. Most of the destitute will be served by Medicaid. And honestly - I don't have much sympathy for a person who, offered elective and preventative care at fair rates, refuses to use them because he prefers having a TPA ostensibly pay for that care.

I don't know why this depresses you. Of course the average American cannot be trusted to handle his own health care.

Maybe he'd surprise us if we compelled him to do so. I get where you're coming from, but I'm sure you get that it's a pretty arrogant place. Joe Sixpacks don't want to learn this stuff, but if you make them do so, I'm confident you'll find a lot of decent negotiators who will wring value from the system that we have not even considered. Why not give them a chance?