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

And now Haley is through the looking glass.

Re: Aca
 

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. 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.

Re: Aca
 

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.

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

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

Re: Aca
 

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.

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

Re: Aca
 

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.

Re: Aca
 

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

Re: Aca
 

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.

Re: Aca
 

?

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

Re: Aca
 

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.

Re: Aca
 

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.

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.

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?

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

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

Re: Aca
 

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.

Re: Aca
 

No one is arguing otherwise.

No it doesn't.

Or at least not relative to anything that matters.

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

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

Re: Aca
 

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?

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.

Re: Aca
 

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

Re: Aca
 

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.

Re: Aca
 

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.

Re: Aca
 

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.

Re: Aca
 

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!

Re: Aca
 

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.

Re: Oops! I did it again!
 

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.

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

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.

Re: Aca
 

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.

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

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.

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

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.

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

I blame the Clintons!

I likes
 

Tim Harris:

"SPICER'S BRIEFING NOTES 03/31/17.

If Trump uses Russian salad dressing, you claim it’s a connection. If he drinks a fifth of Stölichnaya, and drunk-likes all of Anna Kournikova’s pics, you crazy people would claim collusion. Paul Manafort runs his campaign, he asks Russia to hack the DNC, then he steps down when 17 US intelligence agencies find out he’s linked to Putin, Russian Kremlin, and a KGB bank involved in activities also under investigation for money-laundering, fraud and cyber crimes, and you claim it’s a conspiracy.

Trump appoints Jeff Sessions AG who forgot to tell the truth under oath about contacts with Russia, and you claim he lied. Trump calls reports his national security adviser Mike Flynn was coordinating with Russia ‘fake news’ then ‘real’ fires him for lying about totally innocent communications with Russia, and you obsessed Hillary freaks call it cooperation. Trump sends his son-in-law to broker deals with Putin whilst running the family companies to avoid conflict, and you knuckledraggers claim it’s a conflict of interest and want to see the tax returns I promised because you’re nosey privacy invaders like Obama who wire tapped me and the homies.

Since the 2016 election, nearly a dozen Russian diplomats wind up murdered, dead of the natural causes at the ripe old ages of 40 something, and you nuts think it’s suspicious smoke. People get shot every day B. Some Russian diplomat with ties to Manafort slips and falls through his window and is critically injured and you think it’s fishy just because another one was murdered in broad daylight the day before testifying against him. You claim that's somehow shady as if cooperating witnesses, snitches, and cohorts don't always turn up naturally dead or killed by bad hombres, yet you snowflakes are in a mouth froth.

Ridiculous.

This Paul Manafort guy only worked for Trump for a brief, little, teeny weenie time and was a ‘volunteer’ campaign manager who didn’t even get paid by Trump. Putin paid him millions. Happens all the time.

Mike Flynn lawyers up and asks for immunity to testify about nothing but good deeds and you tree huggers are trying to make that some sort of Russia connection. If he and Putin are in Moscow with Manafort getting peed on by Russian hookers whilst reading Hillary's email, brokering oil deals, and installing a Putin puppet government in the US, you salty, obsessive, Lib-Tards will claim it's collusion with Russia. Really? Coincidences. Many Many Many coincidences. #SAD"

TM

Wow
 

http://www.politico.com/f/?id=000001...f-bbd77cd10001

TM

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

When the reset starts in earnest, those of us with even a few dollars will find tremendous bargains.

You're in the top 5% of society, I have no doubt. If something like 2008 repeats (it'll be slower next time... a series of soft landings as standards of living trend downward has already been engineered if you're looking), you'll be fine.

But yeah -- the next one (which is really just the inevitable reckoning we've papered over several times now in the past two decades) is going to be a real heart breaker for a lot of people.

I full expect to live through something awful in the next two decades. I'm hoping I'm dead wrong and pleasantly surprised to the contrary. But I don't see it.

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

It wasn't in the interest of either labor negotiators or municipal politicians to do anything except kick the fiscal responsibility can down the road. "Look! You'll have a bright shiny pension!! (Damned if I know who is going to pay for it.)" Who should have prevented this? Accountants who signed off on the pension plan financials. Pension Plan Trustees who ignored any accountant who did flag it. Municipal finance bond issuers who didn't see this coming when they should have. The worst culprit: The Pension Benefit Guarantee Board. Even if municipal plans are not protected ( I don't think they are) the same crap in the private sector, that is, assuming utterly unrealistic rates of return, has put the PBGC hopelessly in the deep, deep red.

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

Voters who choose irresponsible leaders.

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

Niall Ferguson's a blowhard, but he has a pretty solid view on how cycles like the one we are in resolve. It goes, Insurmountable Economic Problems > Populism > Nationalism > Cold War > Hot War. Stages 2-4 can occur simultaneously.

When all else fails, War!

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

I haven't seen any pension managers on the ballot lately.

I'm with you on the public being blameworthy for a lot of things. But this one looks like a professional/politician/bureaucrat level failure. IBGYBG

Re: Wow
 

Watch Oliver Stone's History of the World on Netflix. He does an hour on Wallace that's really excellent.

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

You selfish bastard. If you want more than 70, you're being greedy. Start smoking and hang-gliding -- make some room for the kids.

Re: Aca
 

Wrong. I want to offer them a choice. I think if given the choice of paying way, way less for HC insurance every month, a lot of them will think they could do better paying for routine care out of pocket. I'm basically advocating allowing everyone in the market to buy catastrophic plans already available to those under 30 through the ACA.

That's why I'm not preventing them from doing so. I'm allowing them to choose. I think your "most" is actually a much smaller "some."

They're not being exposed to risk of routine care cost. There is no "risk" there, as it's elective. They're choosing to have a TPA pay for it for them. In the current climate, that's the only rational choice. If they could save money doing it another way, they'd do so.

I'm arguing for simply testing whether, given more choices, people wouldn't opt for something that might have a positive impact on both costs and quality of care (docs in direct purchase environments focus on medicine, not administrative bullshit... that's what makes concierge attractive to many of them).

We don't know if consumers don't want it. There's never been a direct purchase-at-real-prices market. The closest we have is concierge. At $3,000 a year for ten or so office visits, that indicates a direct purchase model + a catastrophic plan might be a lot more cost effective for a lot of people currently paying for coverage they don't need because the law mandates it.

I'm passing here. I'm not prepared to generally argue ideologies. I was only interested in HC policy here.

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

No, Niall Ferguson is a lying moron.

Re: I am so fucking amused
 

Thanks for the laugh.

Niall Ferguson, that's a good one.

Really. Ferguson. OMG. ROFLOL!

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

Good afternoon. I, Responsible Leader, declare my candidacy for Czar of (Your State Here.)

We are in deep caca, boys and girls. The bridges are falling, the water is full of toxins, the roads are crumbling, your darling children are getting a mediocre education, we can't afford paying pensions to our retired civil servants, your medical insurance is on fire, and you have squat for savings. Some of that I can help; some of it I can't.

I can fix the bridges, fix the roads, clean up the water, hire decent teachers, and give all the pensioners a decent percentage of what we owe them. I can't help you on the medical insurance or the fact that you didn't save much.

To do this, I'm going to tax the hell out of you, because there is no other option.

Vote Responsible Leader Next November!

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

I have a strategy for handling our new dystopia. A wine cellar. If the world truly goes to hell, and we find ourselves in an outer circle, the remaining wealthy will bid up the wine and it will be a sound investment. If it goes one step beyond and we reach the inner circles of hell, I'll at least have the wine to drink.