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I firmly believe that "single payer" would get a lot more support if people stopped talking about it in grandiose themes and noble vignettes and started talking about it in real terms. All the liberals I know are in heavy favor of "single payer" without any of them knowing what the fuck it is.

HERE'S WHAT THE FUCK IT IS.

I've got a medical facility - Al's Medicine. Al's subcontracts to Betty the Biller and Cindy the Client Specialist. I operate in a state where my medical facility is covered by Medicaid. We also take private (employer-provided) insurance, which is underwritten by the following insurance firms: Q, R, S, T, U, V, W, X, Y and Z.

Al's must sign individual contracts with Q, R, S, T, U, V and W. These contracts are "take it or leave it" binding: they say that for ICD code 1, Q will pay Al's $7.50 but for ICD code 1.000000001, Q will pay Al's $0.00 because fuck you, Al's. Note that Q might pay Joe's $6.50 or $9.50 or pi.ie^2 for ICD code 1. Q is entirely within its rights to do so. Al and Joe, on the other hand, are contractually forbidden from discussing their rates for ICD Code 1. If Q gets wind that Al and Joe know what the other are getting, they can drop both because fuck you, Al and Joe. Also know that Joe might not get anything for ICD Code 1 because Q has decided that all of Q's contracted healthcare clients can drive 75 miles to Al's for those services because fuck you, Joe. Also know that Q can tell Al's they'll pay $7.50 for "services" verbally and in writing, but when the actual contract comes through the actual number listed is $2.25 because fuck you, Al's. Also know that they won't tell you what ICD codes they'll pay for, they'll just say "services" and let you resubmit your bills over and over and over again until you find the ICD code that pays out the most because fuck you. Also know that the ICD code they choose to pay for can and will also change because fuck you.

A few other notes: Al's might have to provide, for example, rhogam shots to prevent babies from dying from blood type incompatibiliy. These rhogam shots might cost Al's $28 but Q is going to pay $7 because fuck you, Al's. If you ever wondered why hospitals charge you $40 to hold your baby it's because they're trying to claw back the $21 the insurance company isn't paying for medicine they're required by law to administer (for example). Also note that your involvement, gentle consumer, starts when you get an "explanation of benefits" from the insurance company listing all the outrageous charges the doctor hit you with. It will provide no explanation. It will show how generous they were in all their disbursements and then show you that your doctor's office is going to bill you STILL MORE MONEY because they're such bloodsuckers.

This is where Betty Biller and Cindy Client Specialist come in. Betty makes 10% by pickaxing all the money she can get out of Q. Betty's whole job is knowing what Q pays out on. Betty knows which ICD codes Q pays out what on, and can turn your "normal child checkup" into 42 different codes that pay the maximum rate Q has contracted to pay. She is literally a medical billing bounty hunter. Betty is the back office side while Cindy talks to you, the client - here's what's coming, here's what it means, here's how to get your insurance to pay for this ahead of time, here's how to get preapproval for that.

For those keeping track at home, billing specialists outnumber doctors 2:1 in this scenario.

Multiply times insurance companies R, S, T, U, V and W, who all have their own rates, all have their own codes, all have their own geographic exclusion areas, and probably have seven or eight sub-plans so that it's not actually "V" it's V.a, V.b, V.c, V.d, V.e, V.f and so on. Suddenly, Betty and Cindy look positively useful and you will pay them gladly because the act of billing for care takes three to four times as many man-hours as actually providing that care. Betty and Cindy make good livings and their existence is entirely parasitic on the insurance companie's deliberately opaque, byzantine and antagonistic reimbursement practices.

Not Y and Z, though. Y and Z contract through Medicaid. Medicaid has no patience for that bullshit. They will pay the following amounts on the following ICD codes. Anybody who contracts through Medicaid bills those codes and gets that money. It is known. Y knows, Z knows, Al knows, Joe knows, and all of Al and Joe's clients can fuckin' look it up. And when Medicaid's reimbursements lag behind the real world, it gets turned into a bill that goes to the legislature that raises the rates for everyone.

Al's, in fact, might get better reimbursements out of Y and Z (because of medicaid) than they get out of Q, R S, T, U or V.

Unfortunately you as a patient don't get your insurance through Y and Z because you make more than the poverty level for your county. You get whatever insurance your job provides, which might be V.c, might be Q, might be nothing because you drive for Uber and fuck you.

As a provider, we get to choose who we contract with. We do not get to choose what those providers pay us. And if 50% of your clients work for Microsoft, you bloody well better be able to take V.c, despite the fact that they reimburse at exactly half what Medicaid reimburses at (which is funny, because all your Microsoft mommies make six figures). R, on the other hand, may decide that they'll never cover you because they have enough of your specialty in network, never mind that the nearest provider is a ferry ride away (because this way they don't have to pay for those services).

As an insurer, you get to decide who you contract with. You can pick the providers that are the stupidest, that will accept the lowest rates, that have the lowest conflict rate of you arguing over charges. And you get to discuss this with the HR reps of companies large and small, none of which have any background in medicine, medical billing, accounting or statistics. To no one's surprise, they choose on price.

But the poor people? They pay what the state says they pay, the insurance companies collect what the state says they collect, and they contract with the providers the state says they contract with.

THEY STILL MAKE MONEY.

They're still private insurance companies, privately managing your health care, privately paying out private doctors. It is not "socialized medicine." It is not "universal healthcare." It is not the National Health Service. The healthcare industry is something like a tenth of the US economy; you're never getting that. But you go single payer and all of a sudden things go from back-room knife fights between Q, R, Betty and Cindy to state-mandated pricing and state-mandated coverage.

My future is tied to health care. I've got more in a medical practice than you have in your house.

And I'm a big booster of single payer.

And so's Aetna, who in this example is R.

by: kleinbl00

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There's a great Frontline that answers all your questions. Unfortunately it hasn't been digitized.

The problem with trading up the chain, simply put, is that law enforcement only knows what criminals tell them. They are not constructing parallel cases. They're not making the roads safer, they're filling their quota of speeding tickets.

Torture doesn't work for the same reason - if you tell me you'll stop pulling my toenails off if I tell you who gave me the IED, I'll stick with the pliers so long as my source scares me more than you. Which means all I need to do is give up someone who scares me less than you do - and there's no downside to iteratively throwing names out there.

Let's say I've got four buddies - Alex, Bob, Chuck, Dave and Elvis. You've got my phone and you know that I call all of them. You're going to throw me down the forever hole unless I give up my dealer, and you suspect it's Alex, Bob, Chuck, Dave or Elvis. I play cards with Alex. Bob occasionally buys weed from me. Chuck's a single dad who hits me up for money. Dave gets me work sometimes as a bricklayer and also loves to share his collection of child porn. Elvis works for the Zetas cartel.

I'm going to give them up in the following order:

1) Chuck because he's a drag on my bottom line

2) Alex because I lose money when I play him, even if it's usually fun

3) Bob, because I'll miss that income

4) Dave, because I'll really mis that income

Never) Elvis, because I don't want my entire family to end up beheaded on the side of the road outside Amarillo

Presume, for the sake of kindness, that the DEA can rule out Chuck and Alex immediately. They are obviously, visibly harmless. Bob? The DEA is going to squeeze Bob, who will give up his own list that also doesn't include Elvis. Each one of the people on his list will be squeezed until eventually someone is stupid enough to flip a supplier. That supplier is then going to play the exact same fucking game. Elvis is doing just fine, the DEA is chasing their tails, and low-level addicts are suddenly drug kingpins because they're all narcing on each other.

Let's add some financial incentive to the pot, shall we? Every single person who gets implicated is also subject to DEA seizure. That means they get to take anything that touches drugs. Did you drive a car with drugs in it? it belongs to the DEA. Did you ride in a friend's car with drugs in it? It belongs to the DEA. Store drugs in your house? It belongs to the DEA. Store drugs in your landlord's house? It belongs to the DEA.

Along with everything in it.

Let's take my buddy Dante. He was addicted to Meth. He got clean for the sake of his life, and for the sake of his son. And then his buddy, who helped him get clean, told him that he needed 2 kilos of coke to make it across town by 5 or the Zetas would kill him. So my buddy Dante got the keys out of a mailbox, got in the car and started it up.

The car? The DEA's. The drugs? The DEA's. Dante's buddy? Trading up the chain, giving up Dante rather than the guys the DEA wanted because Dante couldn't make him show up headless on the side of a freeway outside Amarillo. Dante, of course, had no one to give up so he was charged with trafficking and faced a ten year bid for a first offense. Lost his truck, lost all his musical equipment, is a felon forever.

Well yeah. Shouldn't have gotten in the car. No shit. But if you think policing, public order, the war on drugs or any civil good has been advanced by this travesty of criminal justice you're not only high, you're evil.

And that's what's wrong with it. Dante is real. The seizures are real. The dead on the side of the road outside of Amarillo is my sister's ex-boyfriend. And here's the DEA, getting low-level smurfs to snitch on each other for fun and profit while the Coast Guard siezes 225 tons of coke.

kleinbl00  ·  link  ·  parent  ·  post: Pubski: September 20, 2017

    Welp. I'm in the hospital for a week or so. My transplanted kidney is experiencing some antibody mediated rejection. It's got some permanent damage, but with treatment and increased immune suppression, I should get a few more years of use out of it. Grateful for everyday since 2009. Grateful for my donor, and his family. Grateful for good healthcare. Grateful for my kiddos. Grateful for all the people who have supported me since my kidneys failed in 2007.

That's a buddy of mine, couple weeks ago. I've known him since I was three. He's center left. I'm center right. This was my seventh birthday.

He was my main rival through elementary school; the other smart kid. We were the twin towers of nerd-dom. Only he got distracted by other stuff and basically flaked out on school; I think he literally got perfect SAT scores but his academics blew. He now thinks it was the paint chips he ate as a baby because apparently he's got other hallmarks of lead exposure. Me? I started hanging out with the overpass kids and noped the fuck out of academics pretty hard so by the time anyone gave a fuck about achievement we were both too cynical to care.

    The out of pocket cost for these treatments will be approximately $5000. Worth it, but extremely difficult to cover, especially given the amount of unpaid leave from work he has had to take (2 weeks so far, plus at least another 10 days in the next two months for chemo). He's a good, hard-working man who hasn't been able to catch a break when it comes to his health.

We have lunch when I can find time; it's always striking to me because I show up wearing WTFever and he shows up in coveralls with his name on them. perfect SAT score. My life was no bed of roses but fuckin'A.

He's gonna die.

He's three months to the day younger than I am and he's gonna die. He's got two kids; one just graduated high school, I think, and the other is three or four years out. His wife got him all the way through recovery and then decided that she didn't want to be anyone's wife anymore. And his commute is miserable and he's gotta deal with shit like dialysis AGAIN.

I've done well in Ethereum. It's play money, too. And my instinct is to frickin' pay off his gofundme. I mean, there's a girl on the roster there a thousand miles away whose existence I'd forgotten until yesterday and she put $250 towards this guy she prolly hasn't seen in more than 20 years. I've had lunch with him like twice this year and I haven't been here for half of it. Maybe that'll buy him another couple years. But then I put my name on it and it hangs over both of us. Maybe I don't put my name on it and then it hangs over me. I don't know.

His parents are government employees with rippin' pensions but he doesn't talk to them anymore of course and besides, he's a grown-ass man. A grown-ass man whose sister is begging on the Internet to pay his medical expenses because we live in the most advanced Western democracy in the world with the best healthcare in the world and the best doctors in the world and we're crowdfunding someone's renal failure.

I make reality television for a living and my daughter's inhaler costs me $5. Her epipen costs me $5. Her ER visits? A whopping $70 ZOMG. I get hot towels when I fly and he finishes out the day with Gojo and growing up, his was the house the nicest one I'd been in and his mom was on the city council and their cars were always new and I hunted mice so I could sleep and here we are and I don't understand how we've created a society where a million little choices by a million little kids lead us to this place where I keep my bike tools in a Harry Winston bag and he's begging the Internet for another couple years on this earth, please.

So I'm home, and I slept in my own bed, and I started a class in taking apart watches and I've got a feature and a short to mix and what really fucks me up - and has been fucking me up - is my buddy.

I sent him a text saying we were setting up a standing lunch date, my treat, he picks the day of the week and the place. I haven't heard back.

America.

I firmly believe that "single payer" would get a lot more support if people stopped talking about it in grandiose themes and noble vignettes and started talking about it in real terms. All the liberals I know are in heavy favor of "single payer" without any of them knowing what the fuck it is.

HERE'S WHAT THE FUCK IT IS.

I've got a medical facility - Al's Medicine. Al's subcontracts to Betty the Biller and Cindy the Client Specialist. I operate in a state where my medical facility is covered by Medicaid. We also take private (employer-provided) insurance, which is underwritten by the following insurance firms: Q, R, S, T, U, V, W, X, Y and Z.

Al's must sign individual contracts with Q, R, S, T, U, V and W. These contracts are "take it or leave it" binding: they say that for ICD code 1, Q will pay Al's $7.50 but for ICD code 1.000000001, Q will pay Al's $0.00 because fuck you, Al's. Note that Q might pay Joe's $6.50 or $9.50 or pi.ie^2 for ICD code 1. Q is entirely within its rights to do so. Al and Joe, on the other hand, are contractually forbidden from discussing their rates for ICD Code 1. If Q gets wind that Al and Joe know what the other are getting, they can drop both because fuck you, Al and Joe. Also know that Joe might not get anything for ICD Code 1 because Q has decided that all of Q's contracted healthcare clients can drive 75 miles to Al's for those services because fuck you, Joe. Also know that Q can tell Al's they'll pay $7.50 for "services" verbally and in writing, but when the actual contract comes through the actual number listed is $2.25 because fuck you, Al's. Also know that they won't tell you what ICD codes they'll pay for, they'll just say "services" and let you resubmit your bills over and over and over again until you find the ICD code that pays out the most because fuck you. Also know that the ICD code they choose to pay for can and will also change because fuck you.

A few other notes: Al's might have to provide, for example, rhogam shots to prevent babies from dying from blood type incompatibiliy. These rhogam shots might cost Al's $28 but Q is going to pay $7 because fuck you, Al's. If you ever wondered why hospitals charge you $40 to hold your baby it's because they're trying to claw back the $21 the insurance company isn't paying for medicine they're required by law to administer (for example). Also note that your involvement, gentle consumer, starts when you get an "explanation of benefits" from the insurance company listing all the outrageous charges the doctor hit you with. It will provide no explanation. It will show how generous they were in all their disbursements and then show you that your doctor's office is going to bill you STILL MORE MONEY because they're such bloodsuckers.

This is where Betty Biller and Cindy Client Specialist come in. Betty makes 10% by pickaxing all the money she can get out of Q. Betty's whole job is knowing what Q pays out on. Betty knows which ICD codes Q pays out what on, and can turn your "normal child checkup" into 42 different codes that pay the maximum rate Q has contracted to pay. She is literally a medical billing bounty hunter. Betty is the back office side while Cindy talks to you, the client - here's what's coming, here's what it means, here's how to get your insurance to pay for this ahead of time, here's how to get preapproval for that.

For those keeping track at home, billing specialists outnumber doctors 2:1 in this scenario.

Multiply times insurance companies R, S, T, U, V and W, who all have their own rates, all have their own codes, all have their own geographic exclusion areas, and probably have seven or eight sub-plans so that it's not actually "V" it's V.a, V.b, V.c, V.d, V.e, V.f and so on. Suddenly, Betty and Cindy look positively useful and you will pay them gladly because the act of billing for care takes three to four times as many man-hours as actually providing that care. Betty and Cindy make good livings and their existence is entirely parasitic on the insurance companie's deliberately opaque, byzantine and antagonistic reimbursement practices.

Not Y and Z, though. Y and Z contract through Medicaid. Medicaid has no patience for that bullshit. They will pay the following amounts on the following ICD codes. Anybody who contracts through Medicaid bills those codes and gets that money. It is known. Y knows, Z knows, Al knows, Joe knows, and all of Al and Joe's clients can fuckin' look it up. And when Medicaid's reimbursements lag behind the real world, it gets turned into a bill that goes to the legislature that raises the rates for everyone.

Al's, in fact, might get better reimbursements out of Y and Z (because of medicaid) than they get out of Q, R S, T, U or V.

Unfortunately you as a patient don't get your insurance through Y and Z because you make more than the poverty level for your county. You get whatever insurance your job provides, which might be V.c, might be Q, might be nothing because you drive for Uber and fuck you.

As a provider, we get to choose who we contract with. We do not get to choose what those providers pay us. And if 50% of your clients work for Microsoft, you bloody well better be able to take V.c, despite the fact that they reimburse at exactly half what Medicaid reimburses at (which is funny, because all your Microsoft mommies make six figures). R, on the other hand, may decide that they'll never cover you because they have enough of your specialty in network, never mind that the nearest provider is a ferry ride away (because this way they don't have to pay for those services).

As an insurer, you get to decide who you contract with. You can pick the providers that are the stupidest, that will accept the lowest rates, that have the lowest conflict rate of you arguing over charges. And you get to discuss this with the HR reps of companies large and small, none of which have any background in medicine, medical billing, accounting or statistics. To no one's surprise, they choose on price.

But the poor people? They pay what the state says they pay, the insurance companies collect what the state says they collect, and they contract with the providers the state says they contract with.

THEY STILL MAKE MONEY.

They're still private insurance companies, privately managing your health care, privately paying out private doctors. It is not "socialized medicine." It is not "universal healthcare." It is not the National Health Service. The healthcare industry is something like a tenth of the US economy; you're never getting that. But you go single payer and all of a sudden things go from back-room knife fights between Q, R, Betty and Cindy to state-mandated pricing and state-mandated coverage.

My future is tied to health care. I've got more in a medical practice than you have in your house.

And I'm a big booster of single payer.

And so's Aetna, who in this example is R.

Houseplants are important psychologically. They demand nothing from us other than water and light, yet they are a living thing whose existence depends on us. By requiring our care they allow us to shift our focus from ourselves to something else, but at a much lower concentration than pets or humans. They're useful for staving off depression. The hard part is when the depression wins.

Mine started about ten. I'd had a couple houseplants and an aquarium in my room in 5th grade; when we moved in sixth I took the opportunity to plan a large skylight (which I never got - my parents put them in two other rooms but) and hang up a couple 4' grow lamps. By the time I was sixteen I had maybe 25 pots of various foliage, two aquariums and a hand-me-down cage full of finches.

By the time I was seventeen my sister was stealing my shit to sell to her friends, my parents weren't interacting with me unless it was to give me shit, I was a full-blown exercise bulimic and I was trapped.

And I let it all die.

At one point I went away for four or five days and my parents broke into my room because they suspected there were things to be fed in there. They apologized when they realized everything was long since dead.

But they never wondered what the fuck happened, and they never did anything about it.

I like green, growing things. My own little Silent Running in the middle of the fucking New Mexico desert was my escape capsule. And the fact that I couldn't keep it alive still messes me up.

The fact that my parents never gave a fuck made me angry for a very, very long time.