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

[Tyrone Slothrop]

Originally Posted by sebastian_dangerfield

What's the main driver of insurer exits? The pools are sicker than anticipated, translating to losses.

You can think of only one solution to that problem? You're a creative guy.

[Tyrone Slothrop]

Originally Posted by ThurgreedMarshall

Seems like if Obamacare fails it will be because this administration refuses to enforce the mandate.

http://www.politifact.com/punditfact...-death-spiral/

TM

It's totally bizarre to me that the Republicans can think that failing healthcare is going to be a plus for them, politically. They run the government now. If they can't provide what people want, voters will look somewhere else.

[Adder]

Originally Posted by sebastian_dangerfield

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.

No one is arguing otherwise.

This inflates prices generally across the board for preventative, catastrophic and chronic care.

No it doesn't.

Or at least not relative to anything that matters.

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.

They won't, but they will pay more than the insurance companies do now.

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'm generally in favor of competition, but few will shop for the cheapest doctor.

[Adder]

Originally Posted by sebastian_dangerfield

Docs hate insurers, and they're not the ones robbing people blind.

Docs aren't robbing people blind (question because I'm not positive that's what you're saying)? I dunno. Aren't American docs substantially better compensated than anywhere else in the world?

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.

Call me crazy, but I think we should minimize the number of losers and maybe pick them on a critirea other than ability to pay.

[ThurgreedMarshall]

Originally Posted by sebastian_dangerfield

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.

Kitty cats write the most provocative novels. This happens. No...Before you say it doesn't, it does. Full stop.

Originally Posted by sebastian_dangerfield

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.

I am not going to argue every point I would like to in this treatise, because it doesn't matter. Your argument is fatally flawed from a number of perspectives. But there's really no point in drawing your attention to them because your mind is made up.

TM

[Tyrone Slothrop]

Originally Posted by sebastian_dangerfield

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...)

Part of the reason this debate confuses is that Sebby uses language that is the opposite of what he means. What he calls "true insurance" is actually forbidding people from insuring risks that most people want to insure. When he says he is a "Libertarian," he means that he is the sort of libertarian who believes markets would achieve better outcomes if other people were forced to do what he thinks would be best instead of what they actually want to do, something not libertarian at all.

Most people would prefer to buy comprehensive coverage that protects them not only from paying the costs of catastrophic and chronic care, but also preventative and elective care. Contra Sebby, this is not because people can't be trusted to handle his own health care, but because they prefer to pay to let someone else incur those risks. Sebby sees a market failure that makes him want to forbid people from transacting with each other for such insurance, a bizarre thing to call libertarian.

If there is a libertarian strain here, it is the knee jerk objection to the government provision of services, and the concomitant blindness to using the government to screw people while pretending it is their own fault.

[Greedy,Greedy,Greedy]

Originally Posted by ThurgreedMarshall

Kitty cats write the most provocative novels. This happens. No...Before you say it doesn't, it does. Full stop.

I am not going to argue every point I would like to in this treatise, because it doesn't matter. Your argument is fatally flawed from a number of perspectives. But there's really no point in drawing your attention to them because your mind is made up.

TM

Look, I only took about eight or nine econ courses twenty five years ago and my work for the health care industry has all been just deal stuff, so I'm no expert, but his treatise still reads to me just about like a pro se plaintiff's brief arguing that imprisonment by the state violates the 8th and 13th amendment.

I mean, you know where he gets it, but, come on, to quote 43, it's just some weird shit.

[sebastian_dangerfield]

Part of the reason this debate confuses is that Sebby uses language that is the opposite of what he means. What he calls "true insurance" is actually forbidding people from insuring risks that most people want to insure.

Does your car insurance pay for you to get oil changes? New tires? Does your homeowner's insurance pay for you to get an appraisal of the cost of a new roof? Does it pay for you to have the home painted?

I understand insurance. I'd invite you to research the difference between a TPA and insurance, and get back to me as to which our HC insurance system resembles.

When he says he is a "Libertarian," he means that he is the sort of libertarian who believes markets would achieve better outcomes if other people were forced to do what he thinks would be best instead of what they actually want to do, something not libertarian at all.

The people have never been offered what I've proposed. And you have no proof that if a working form of it were implemented, the overwhelming majority of people would prefer to go back to the system we have. Your proposition is 100% speculation served as fact.

Most people would prefer to buy comprehensive coverage that protects them not only from paying the costs of catastrophic and chronic care, but also preventative and elective care.

And your proof, in the form of them selecting this option where given a choice of the alternative I propose, is...?

Contra Sebby, this is not because people can't be trusted to handle his own health care, but because they prefer to pay to let someone else incur those risks. Sebby sees a market failure that makes him want to forbid people from transacting with each other for such insurance, a bizarre thing to call libertarian.

I don't seek to forbid anything. You put those words in my mouth. I only advocate allowing the market to decide. Right now, our system disincentivizes, if not outright precludes, the sale of exclusively catastrophic plans.* And even if you have one, your routine care remains overpriced due to the impact of price-inflation by providers to offset discounts demanded by insurers.

If there is a libertarian strain here, it is the knee jerk objection to the government provision of services, and the concomitant blindness to using the government to screw people while pretending it is their own fault.

How's the govt screwing anyone under my suggestion?
_______________
* Under 30 only, or hardship exemption.

[sebastian_dangerfield]

Originally Posted by Greedy,Greedy,Greedy

Look, I only took about eight or nine econ course twenty five years ago and my work for the health care industry has all been just deal stuff, so I'm no expert, but his treatise still reads to me just about like a pro se plaintiff's brief arguing that imprisonment by the state violates the 8th and 13th amendment.

I mean, you know where he gets it, but, come on, to quote 43, it's just some weird shit.

It is novel. I said as much yesterday. But your position, and the position of everyone else here, is "We should do more of the same." Yes, the ACA is pretty much more of the same. It's not a radical fix of any sort. Well intentioned, comprised of some useful adjustments, sure, but largely conventional, and not too far from just doing the same thing over and over and expecting a different result.

I understand lawyers get married to precedent and are blindered by risk avoidance, so dicking around at the margins, which is the ACA, is a fix close to your heart. Try to have an open mind. I'm not suggesting my idea is a definite winner, but at a minimum, incorporation of some elements of it would make a positive difference.

Honestly, I don't know how anyone can argue with at least attempting to lower the private pay price for direct consumers (which necessarily creates more price transparency)? How is this not an item on which we all agree? This would help the people on bronze plans!

[Greedy,Greedy,Greedy]

Originally Posted by sebastian_dangerfield

It is novel. I said as much yesterday. But your position, and the position of everyone else here, is "We should do more of the same." Yes, the ACA is pretty much more of the same. It's not a radical fix of any sort. Well intentioned, comprised of some useful adjustments, sure, but largely conventional, and not too far from just doing the same thing over and over and expecting a different result.

I understand lawyers get married to precedent and are blindered by risk avoidance, so dicking around at the margins, which is the ACA, is a fix close to your heart. Try to have an open mind. I'm not suggesting my idea is a definite winner, but at a minimum, incorporation of some elements of it would make a positive difference.

Honestly, I don't know how anyone can argue with at least attempting to lower the private pay price for direct consumers (which necessarily creates more price transparency)? How is this not an item on which we all agree? This would help the people on bronze plans!

To be clear on my position, my position is (a) health care financing is complex, and there is nothing anyone is going to do to change that, so there is no simple solution and silver bullet, whether it goes under the name of single payer or free market solutions; (b) we need an increasing move to outcome based compensation throughout the system, so we aren't paying quacks to kill people; (c) we need increased focus on data-driven approaches, including looking hard at what results in the best outcomes at the best prices in other systems, and as we get these I think it will become clearer and clearer that the insurance industry as a whole adds little but cost to the system and can be phased out or their cut pushed back; and (d) whatever solution we use, we have to take care not to kill the most productive research system in the world, even if it is disproportionately paid for by the US, but we have to start making cost-sharing in phrama and device development part of our treaty process.

Some here will share some of my views, but some won't.

[Greedy,Greedy,Greedy]

What do you say we all send Pence, c/o the White House, a male chastity belt. There are some nasty looking ones on Amazon for under $50. I think it would be hepful.

[ferrets_bueller]

Today's Horribly Scary Statistic, Non-Trumpazoid Division:

Unfunded pension obligations have risen to $1.9 trillion from $292 billion since 2007. A financial crisis is steaming along as the Boomers retire, their pensions default, and they can't support themselves on social security alone. Hardest hit: Municipal employees like cops and teachers, whose pension plan return assumptions are so far beyond optimistic as to constitute criminally negligent magical thinking.

Boomers' children will NOT be happy about this. Instead of visiting their parents in a warm weather vacation villa, they will have their parents living in the spare bedroom.

https://www.bloomberg.com/view/artic...kets-to-ignore

A disclaimer: Some of the websites cited in the Bloomberg piece are run by "Its The End Of The World As We Know It, Here's Where To Buy A Bomb Shelter And A Machine Pistol To Protect Your Family" people. That said, the numbers are or should be terrifying.

Disclaimer 2: Sebby probably agrees with me on this. Please don't hold that against me.

[Tyrone Slothrop]

Originally Posted by sebastian_dangerfield

Does your car insurance pay for you to get oil changes? New tires? Does your homeowner's insurance pay for you to get an appraisal of the cost of a new roof? Does it pay for you to have the home painted?

I understand insurance. I'd invite you to research the difference between a TPA and insurance, and get back to me as to which our HC insurance system resembles.



The people have never been offered what I've proposed. And you have no proof that if a working form of it were implemented, the overwhelming majority of people would prefer to go back to the system we have. Your proposition is 100% speculation served as fact.



And your proof, in the form of them selecting this option where given a choice of the alternative I propose, is...?



I don't seek to forbid anything. You put those words in my mouth. I only advocate allowing the market to decide. Right now, our system disincentivizes, if not outright precludes, the sale of exclusively catastrophic plans.* And even if you have one, your routine care remains overpriced due to the impact of price-inflation by providers to offset discounts demanded by insurers.



How's the govt screwing anyone under my suggestion?
_______________
* Under 30 only, or hardship exemption.

Most people want to buy health insurance that covers -- insures them against -- the costs not only of critical care, but also of preventative care. You have been very clear that you would like to force consumers not to do this -- i.e., to prevent them from obtaining the insurance they want -- because you think that once forced into the market to make consumption decisions individually rather than bundled, consumers would force prices down and manage their own care more efficiently. I guarantee you that most people would feel screwed if they were prevented from buying coverage for preventative care, and instead forced to go into that marketplace on their own.

What you're suggesting is akin to saying that we would all be better off if auto insurance had per incident deductibles of $100K, because people would be covered for massive injury but would drive more carefully and exercise better care in paying for repairs if they couldn't just pass costs to insurers. Even if this were true as far as it goes, what you miss is that people are risk-averse are prefer to buy insurance rather than to be exposed to these risks. So too with healthcare.

What you're underscoring is that libertarianism is a nonsensical concept here. Consumers' choices -- their freedom -- are constrained both by the government and by private parties. You can't get the peculiar flavor of insurance you want if the government requires more, but you also can't get it if other consumers don't want it or insurers don't want to provide it. In all three cases, your freedom is limited in a meaningful way. The conceit of libertarianism, that the only limitations on your freedom that count are those dictated by the government, is a distinction without a meaningful difference.

[greatwhitenorthchick]

Originally Posted by ferrets_bueller

Today's Horribly Scary Statistic, Non-Trumpazoid Division:

Unfunded pension obligations have risen to $1.9 trillion from $292 billion since 2007. A financial crisis is steaming along as the Boomers retire, their pensions default, and they can't support themselves on social security alone. Hardest hit: Municipal employees like cops and teachers, whose pension plan return assumptions are so far beyond optimistic as to constitute criminally negligent magical thinking.

Boomers' children will NOT be happy about this. Instead of visiting their parents in a warm weather vacation villa, they will have their parents living in the spare bedroom.

https://www.bloomberg.com/view/artic...kets-to-ignore

A disclaimer: Some of the websites cited in the Bloomberg piece are run by "Its The End Of The World As We Know It, Here's Where To Buy A Bomb Shelter And A Machine Pistol To Protect Your Family" people. That said, the numbers are or should be terrifying.

Disclaimer 2: Sebby probably agrees with me on this. Please don't hold that against me.

I was only incidentally involved in the Stockton and Vallejo bankruptcies (my firm at the time was heavily involved, but I only work with ERISA plans in bankruptcy, not gov't plans, so I only got a question or two), but it did surprise me that other state/local plans didn't start scaling back assumptions and benefits in light of what happened there. And didn't the judge in the Stockton case rule that municipalities facing bankruptcy could scale back pensions no matter what the rules are under the big state public employee funds (like CalPERS)? Why didn't that happen in order to prevent this?(question not directed at you, ferrets, just to anyone who might know). I think part of the problem may be that the benefits are enshrined in some state constitutions.

[Greedy,Greedy,Greedy]

Originally Posted by ferrets_bueller

Today's Horribly Scary Statistic, Non-Trumpazoid Division:

Unfunded pension obligations have risen to $1.9 trillion from $292 billion since 2007. A financial crisis is steaming along as the Boomers retire, their pensions default, and they can't support themselves on social security alone. Hardest hit: Municipal employees like cops and teachers, whose pension plan return assumptions are so far beyond optimistic as to constitute criminally negligent magical thinking.

Boomers' children will NOT be happy about this. Instead of visiting their parents in a warm weather vacation villa, they will have their parents living in the spare bedroom.

https://www.bloomberg.com/view/artic...kets-to-ignore

A disclaimer: Some of the websites cited in the Bloomberg piece are run by "Its The End Of The World As We Know It, Here's Where To Buy A Bomb Shelter And A Machine Pistol To Protect Your Family" people. That said, the numbers are or should be terrifying.

Disclaimer 2: Sebby probably agrees with me on this. Please don't hold that against me.

It's important that we all socialize our kids to think of having us around is a good thing, not a burden. And we want more than a spare bedroom.