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comment by user-inactivated
user-inactivated  ·  1505 days ago  ·  link  ·    ·  parent  ·  post: Why everyone hates the GOP's new healthcare plan

Did you know that 2.5 millilon employees work in healthcare insurance and that a single payer option would probably reduce that in a huge way, creating a massive group of unemployed people? There are dozens of major insurance companies who, in the course of daily business operations, duplicate the work that is being done at competing companies. Obviously, Blue Cross' accounting department isn't going to do the accounting for Cigna, and so you get two accountants doind the same parallel work multiplied across all the companies. But if the US Gov't is going to do all the work in a single payer system, you'll have a massive cut in employment. No way around it. I don't think people realize that the sudden disappearance of probably 1.5 million jobs will be a reality in that case. Esepcially not Trump who has advocated for single payer and ran on a major employment focus.

But, as a Libertarian, healthcare is a strange beast. They have a moral obligation to give away their services to those who need them, and this has often been given as a reason why they don't fit into the 'free market' argument. But that 'given away care' only adds up to 39.5 billion. To put it in perspective, those costs are less than 6% of a hospital's costs, and should only add up to a significant, but not untenable price increase to the end user. Of course they're not evenly distributed costs, some hospitals are going to see higher costs than others based on demographics. But in a separate study (where the numbers are less than 6 percent in the first place) they found that the worse-off hospitals (top quartile) spend 2.73% or more on charity care, and 3.49% on bad debt (people who don't pay). So those numbers are simliar. Even if we say that on the aggregate hospitals pay 10% to give to charity care and bad debt, then we still can't justify why healthcare costs so damn much.

The ACA was a mess, and the experiment failed. Costs went up, way up. Certainly there were more people covered, but in one of the only analyses of multiple streams of information and not just a survey, Goldman Sachs came to the conclusion that there were 17 million people insured by 2015. But, of those 17 million, 11 million were gains from the expansion of medicare. 2 more million were from aging into medicare. 3 million were the ones who actually purchased insurance that didn't have it before.

But there was also this legal mandate that made it mandatory to get insurance of suffer a penalty. Also, a lot of people were able to stay under their parent's insurance until they were 26, and they were counted as well. So how many people who had pre-existing conditions and couldn't get insurance before actually got it as a result of ACA? I've heard anecdotes, but has anyone seen the numbers?

So if we want to solve this whole thing, it seems like there are some problems that we've been talking about as if they're true, when they aren't. 20 million people aren't about to lose covereage.





WanderingEng  ·  1505 days ago  ·  link  ·  

    Did you know that 2.5 millilon employees work in healthcare insurance and that a single payer option would probably reduce that in a huge way, creating a massive group of unemployed people?

Are you arguing in favor of bureaucracy as a jobs program?

user-inactivated  ·  1505 days ago  ·  link  ·  

As I wrote it the thought came to my mind. Ha! Arguing for inefficiency was actually hard to type, but it was true so I wanted to stick with it. It's just an unintended consequence of industry nationalization when broad.

But I don't think that market inefficiency is the same as bureaucracy. Market forces are already paring away at this inefficiency through automation of accounting, billing, etc so that there are fewer people being inefficient than ever. If this was the government, there would be no profit incentive to push this change ahead. As an example, many companies are already outsourcing their accounting and payroll departments to businesses like ADP. So that inefficiency is not going to be possible forever.

goobster  ·  1505 days ago  ·  link  ·  

How about a retraining program and we can turn them into border guards and ICE agents!

user-inactivated  ·  1505 days ago  ·  link  ·  

Someone get this man a government agency to run!

OftenBen  ·  1505 days ago  ·  link  ·  

Minor point about 'automated billing/accounting.'

I work in medical research. I write up and authorize orders for a broad range of research sponsored medical testing. In theory, our system is set up in such a way that when I write the order, it sends the bill to my research account, and the patient never even knows that there was a charge. In practice, about half the time, my patients get a bill and are very vocal about it (Thankfully).

This isn't to shut down the point entirely, just to illustrate that automation when taken as a class, still has a lot of bugs to be worked out, and until such a time that happens, it actually takes more work than if the robo-biller hadn't been involved at all.

user-inactivated  ·  1505 days ago  ·  link  ·  

Totally agree there.

Honestly the whole thing confuses the hell out of me that healthcare is so expensive and so inefficient.

Why hasn't someone come out with a better business model yet? I've heard of these little medical co-ops and that interests me. You just pay a subscription fee to a doctor and then you have no other co-pays etc. But they're rare.

kleinbl00  ·  1505 days ago  ·  link  ·  

Healthcare is expensive and inefficient because the seller and the buyer must pass their interactions through a for-profit third party that has no responsibility to either the buyer or the seller. It's the same reason a divorce can be had for $400 in filing fees but a contentious divorce can be millions.

Three sides to every story

Concierge medicine is basically cutting the insurance company out of the equation. Unfortunately it rarely covers catastrophic events, trauma, any of that stuff you tend to have insurance for. We knew a few doctors in LA that offered concierge service, and we've looked long and hard at it ourselves. Why? Because you get to charge a monthly that you pretty much never have to provide any services for and the people who buy it are rich as fuck. Somebody who says "I'm going to pay $50 extra a month so that if I need to go to urgent care it's free" is a hypochondriac, not a genius. Make the umbrella big enough to cover the catastrophic stuff and suddenly you're Aetna. Ain't no concierge service gonna do shit for you if you develop cancer or lupus or MS.

jadedog  ·  1504 days ago  ·  link  ·  

    The ACA was a mess, and the experiment failed. Costs went up, way up. Certainly there were more people covered, but in one of the only analyses of multiple streams of information and not just a survey, Goldman Sachs came to the conclusion that there were 17 million people insured by 2015. But, of those 17 million, 11 million were gains from the expansion of medicare. 2 more million were from aging into medicare. 3 million were the ones who actually purchased insurance that didn't have it before.

I'm trying to process your argument first. Your article talks about health care costs rising.

    Prices for medicine, doctor appointments and health insurance rose the most last month since 1984.

Correct me if I'm wrong here, but I'm pretty sure that ACA only dealt with the insurance part of it. The medicine costs and the doctor costs aren't regulated. Because of those rising costs, the insurance piece of it goes up.

In some ways, it may be because of the ACA that the costs went up. If more people have access to doctors, then more people went to the doctor and got medicine. If many of those people were sicker than anticipated, that might have driven up the costs of medicine and doctor's visits on an aggregate basis.

But then wouldn't that be a success for the ACA since those people are now going to the doctor when they wouldn't have? I'll grant you that I'm making up a scenario that neither of us can prove based on your data, but I don't think it can be shown that's not what happened either from this limited data.

    Goldman Sachs came to the conclusion that there were 17 million people insured by 2015. But, of those 17 million, 11 million were gains from the expansion of medicare. 2 more million were from aging into medicare. 3 million were the ones who actually purchased insurance that didn't have it before.

I didn't look at your data because Forbes has a script I don't want to pass. But I did look up more data sets to see if I could find other data.

Here's some from Urban Institute. as reported in CNN Money:

    Obamacare has made it easier for Americans to access health care when necessary. The share of adults who said they had to skip going to the doctor because of costs dropped by nearly 19% between 2013 and 2015, according to a new Commonwealth Fund report.

    Also, the Urban Institute issued a report Wednesday that found 4.4 million children could lose their coverage if Congress repeals but doesn't replace Obamacare. Some 88% of these children would be in families with working parents, and 54% would be white.

    The number of uninsured parents would rise by 7.6 million, with nearly 86% of them in families with at least one person working part time or full time.

    A total of nearly 30 million people would become uninsured if lawmakers repeal but don't replace Obamacare, according to Urban Institute. The repeal would do away with not only the individual exchanges, but also other provisions such as Medicaid expansion and letting children stay on their parents' health plan until age 26.

It's from an article from December 2016 in CNN Money.

According to the Urban Institue, 7.6 million parents could be uninsured, 4.4 million children and 30 million people total including the Medicaid expansion.

    So how many people who had pre-existing conditions and couldn't get insurance before actually got it as a result of ACA?

I'm not sure how your question about how many people have pre-existing conditions is relevant. Whether someone couldn't get insurance before because of cost or because of pre-existing conditions doesn't make much of a difference. They're still not covered and couldn't get insurance if the ACA is repealed.

Interestingly, the proposed plan leaves pre-existing conditions, so the estimates of people who could lose coverage are those people who can't afford it, presumably.

Edit: Just saw this . In a video by CBS News, the Brookings Institution estimates 15 million may lose coverage under Trumpcare as proposed at this point on 3/10/17.

user-inactivated  ·  1504 days ago  ·  link  ·  

The ACA was a huge attempt to control health care costs as well as increase access to care under the auspices that mass enrollment of healthy people would in turn lower the risk pool and thereby costs. It didn't happen, but that was one of the goals. Also, it helps to remember that the ACA was supposed to be straight up single-payer healthcare at the outset. This resultant thing is just a weird compromise that pays off the insurance companies.

So if it was up to me, children would be covered until 18 at least with a CHIPS-type program. It's a moral obligation to take care of those who can't take care of themselves for me. That would still leave the market to develop solutions and provide other options (which I don't think will look similarly to what we do now; it's unsustainable).

The reason I want to look at the pre-existing conditions question is that the number seems really really high when they say that 15 million people will be losing healthcare. And so when I started digging I found out that the number largely includes a huge expansion of Medicare which right off the bat included an 'increase' of 11 million people as insured. They're not really insured in the common understanding of the word, so it's misleading to say that they'll lose insurance coverage. They're just restructuring the medicare program and they'll lose access to that.

All in all, measuring insurance coverage is a ridiculous starting point. I don't want people to be insured. I want them to get the healthcare they need. In a perfect world for me that comes from the free market, but health care is a strange economy because as kleinbl00 pointed out, there is a disinterested, always paid third party in the room that just keeps raising prices without regard to what it does to the customers on either side. I think that has a lot to do with how hard it is to become a health insurer due to regulation (i.e. I can't start a health insurance company to compete due to huge and multiple barriers to entry even on a small town-level scale).

You see a simliar, thought not exactly the same by any means, argument in the internet side of things. People bitch about internet costs, and Comcast says you can go fuck yourself because they know you can't buy it from anywhere else due to regulation. Then you say fine, I'll start my own ISP with blackjack and hookers. And you can't, because Comcast has regulated monopolistic access to the wiring needed. And you can't, because Comcast lobbies to keep it that way. So you end up in a high-cost no competition situation where it would make sense for your city to start up an ISP and run it as a state-owned entity, giving the same people who fucked you over by cozying up to Comcast control over your internet access.

I don't think the government is my friend. I think they are in the pockets of a lot of people. I think that if I can remove them from my life as much as possible it increases my liability and risk personally, but that is a cost I am willing to pay. So I don't want them in healthcare.

jadedog  ·  1503 days ago  ·  link  ·  

    So if it was up to me, children would be covered until 18 at least with a CHIPS-type program. It's a moral obligation to take care of those who can't take care of themselves for me. That would still leave the market to develop solutions and provide other options (which I don't think will look similarly to what we do now; it's unsustainable).

If the ACA was not sustainable, then Trumpcare as drafted so far will also be unsustainable. They're basically the same system. The only difference is in the amount of tax credit and how much the insurance companies can charge.

In this video , rep. Tim Ryan says that in Ohio, the head of the Ohio hospital association says that 1 million people may lose their coverage under the new Trumpcare as drafted at this point and 25% of hospitals will close.

If it's unsustainable to have insurers pull out of the market, it will be less sustainable not to have hospitals to give care at all.

Looking at a study the GAO did that was released in 2013, the factors of the growth of health care costs are the aging population, more people seeking health care under the new insurance programs and technological advancements in health care.

    Federal health care spending is expected to continue growing faster than the economy. In the near term, this is driven by increasing enrollment in federal health care programs due to the aging of the population and expanded eligibility. Over the longer term, excess cost growth (the extent to which growth of health care spending per capita exceeds growth of income per capita) is a key driver. Slowing the rate of health care cost growth would help put the budget on a more sustainable path. There is general agreement that technological advancement has been the key factor in health care cost growth in the past, along with the effects of expanding health insurance coverage and increasing income, but there is considerable uncertainty about the magnitude of the impact that the different factors will have on future health care cost growth.

Neither the ACA nor the proposed Trumpcare plan touches on these issues.

Hoping the market would develop solutions on its own when the healthcare industry is a monopoly is unrealistic. There's no incentive for the market forces to work.

The similarity of health care to Comcast is that they're both monopolies. The difference is that people can walk away from their internet service. People cannot walk away from health care. Their lives literally depend on it.

    I don't think the government is my friend. I think they are in the pockets of a lot of people. I think that if I can remove them from my life as much as possible it increases my liability and risk personally, but that is a cost I am willing to pay. So I don't want them in healthcare.

I'm curious how far you go with this philosophy. In this video , Obama talks with Bill Maher (could Bill Maher be any more in love with Obama?) about all the ways that government has socialized a number of institutions. Schools, prisons, retirement (social security) and elder health care (medicare) are some examples. Are you willing to allow the privatization of schools and prison? As Obama notes, if prisons are privatized, there will be a bigger incentive to incarcerate people. If schools are privatized, the rich will become the only people who can afford going to school, creating an elite class and an uneducated one.

Are you in favor of privatizing schools and prisons?

You mentioned single payer health care which is basically government sponsored health care. Are you in favor of single payer health care? If so, wouldn't this be more government intervention, not less?

thundara  ·  1505 days ago  ·  link  ·  

    Did you know that 2.5 millilon employees work in healthcare insurance and that a single payer option would probably reduce that in a huge way, creating a massive group of unemployed people? There are dozens of major insurance companies who, in the course of daily business operations, duplicate the work that is being done at competing companies. Obviously, Blue Cross' accounting department isn't going to do the accounting for Cigna, and so you get two accountants doind the same parallel work multiplied across all the companies. But if the US Gov't is going to do all the work in a single payer system, you'll have a massive cut in employment. No way around it. I don't think people realize that the sudden disappearance of probably 1.5 million jobs will be a reality in that case. Esepcially not Trump who has advocated for single payer and ran on a major employment focus.

FWIW, even countries with fully socialized medicine have their own private healthcare insurance industries (ex: UK). But even so, this strikes me as a backwards argument: health insurance is too expensive, so we should preserve the inefficiencies and bloat already present in the system.

So far, the clearest summary of the ACA's shortcomings has been that it addressed health insurance coverage without doing enough to address costs. So now you have fewer uninsured people waiting until the last minute to get treatment instead of preventative care, and fewer insured people being denied the coverage the payed for due to undisclosed domestic violence. But the drugs, the scans, and the doctor salaries are still roughly the same. And medicare still can't negotiate drug prices.

So the delta flow of money is still heavy in the direction of providers.

user-inactivated  ·  1505 days ago  ·  link  ·  

Well they thought they were going to address costs by making healthy people join, lowering the overall risk pool, and thus lowering premiums. But it didn't happen. It's not like they didn't have a logical plan to lower costs.

The idea that medicare can't negotiate drug prices is comical.

"Excuse me Mr. Taxpayer, can you bend over and let my rich friend get right up in there? Oh you can't? What about if I made a law? What now? That's a good chap."

thundara  ·  1505 days ago  ·  link  ·  

On the lists of politicians that you may surprisingly agree with: Bernie Sanders

user-inactivated  ·  1505 days ago  ·  link  ·  

I like Bernie Sanders personally. He's genuine and believes he's doing the right thing. He's not owned by corporations and he cares about his constituents. We don't agree politically in broad strokes, but on this I don't see a downside. Why not let the gov't negotiate like anyone else. Companies can always say no if they would lose money.

kleinbl00  ·  1505 days ago  ·  link  ·  

You're quoting one study, by Goldman Sachs, which uses insurance industry data. It conflicts with most everyone else's data, and is also a year old. Which doesn't sound like much until we remember that it didn't go into effect until 2013. In 2016 alone, 9 million people signed up through healthcare.gov, Those are, by definition, people who aren't getting it through their parents, workplace or medicare.

user-inactivated  ·  1505 days ago  ·  link  ·  

That data is only people who have signed up for plans, not those who are actually covered. From the glossary at the bottom:

The cumulative metric represents the total number of people who have submitted an application and selected a plan, net of any cancellations from a consumer or cancellations from an insurer that have occurred to date. The biweekly metric represents the net change in the number of non-cancelled plan sections over the two-week period covered by the report.

To have their coverage effectuated, consumers generally need to pay their first month’s health plan premium. This release does not report the number of effectuated enrollments.

NYT says one-fifth of those didn't pay in 2014. So if that continued then it's 7, instead of 9 million.

And it makes sense that it would have only been 3 milion or so the first year, and gone up to 7 by now, because the penalty only went into effect for 2015's taxes.

As well, just because 7 million people signed up, or even 9 if you use your number from CMS, it doesn't mean that 7 million new people were covered. It means that 7 million people used that market to get covereage. That's not to say that they didn't have another option prior to the healthcare law. Or even currently have other options but decided to use healthcare.gov

When I worked for REI, I had insurance as a part-timer, but when ACA came that was not possible any longer because the insurance didn't meet the minimum requirements. Those requirements were unimportant to me and many of the people who used that insurance, but in making the changes, REI realized they would not be able to provide it at any sensible cost and cancelled the program. They encouraged us to seek out options on the exchange. When I did that, I found out how much more expsensive that would be, and decided not to carry insurance. I then changed jobs into a position with REI where I was full-time. The other people I know either went onto their spouse's insurance or to the exchange which was dramatically more expensive. But they would be counted for the numbers at healthcare.gov

kleinbl00  ·  1505 days ago  ·  link  ·  

And my freelance plan that we'd grandfathered into because of changes in state law was legally terminated by our insurance company so that they could charge us $800 a month instead of $300 and we didn't buy on the market either. But listen:

My contractor with the three kids by two different women and the dual DUI convictions and the missing teeth has health insurance and he didn't. And so does his brother, and so does his uncle, and so does his boss. We can sling anecdata at each other all day but the bottom line is, your argument - "it seems like there are some problems that we've been talking about as if they're true, when they aren't" - is tenuous. It's a bummer for you that the ACA killed your sweetheart insurance but you found other means. It's a bummer for me that the ACA killed my sweetheart insurance but I found other means. But I run out of fingers before I finish counting the friends and acquaintances of mine who had healthcare after 2013 that didn't before and that's a success.

user-inactivated  ·  1505 days ago  ·  link  ·  

You're so condescending that it's hard to listen to you. But listen:

People having healthcare is good. My argument is that the repeal of the ACA is being resisted under the argument that 20 million people are losing healthcare. I am arguing that this is false, and should not be repeated as it is not a true consideration of the facts, regardless of the margin of error in any of our surveys and research. I say it's 3-7 mil, you say 9. It's not 20.

The measure of the success of the bill should not be a nominal counting of people with insurance, but the cost and benefit of that plan. The ACA has raised costs dramatically while making improvements that could have been made by expanding medicare, and creating a high-risk pool that would serve to cover those with pre-existing conditions at a subsidized rate without creating a government mandate to support insurance companies.

The ACA and this replacement could have been written by the insurance companies themselves. They have no incentives to improve, cut costs, negotiate strongly, or benefit the customer, you're going to buy it anyway because of the way insurance laws prevent competition, and if you don't, you're going to pay a lot more when you need it.

Hell, Blue Cross is a non-profit and somehow made 100 million last year while bemoaning the terrible losses that they took on ACA customers.

kleinbl00  ·  1505 days ago  ·  link  ·  

    Did you know that 2.5 millilon employees work in healthcare insurance and that a single payer option would probably reduce that in a huge way, creating a massive group of unemployed people?

If you've been following Pubski at all for the past three years, you're aware that I've been building a healthcare facility with my wife, the doctor. You probably didn't know that she used to help design benefits plans, or that a good friend of ours was the benefits coordinator for Cedars Sinai, or that I spent two years designing implantable medical devices. I didn't bring it up because it isn't relevant to your argument ("20 million people aren't about to lose covereage.")

I unmuted you because I thought you could be civil. Prove me right on this one, not wrong.

To that argument - that 20 million people aren't about to lose coverage - you have one study. That study is an outlier, and two years old. I pointed out that Medicare's own page says something else; you observed that two years ago, not everybody paid. So you deep-dived on that number and now here you are saying 3 to 7 doesn't equal 20, and you're right. But that number also doesn't count the state exchanges:

My broader point is that your argument is one that I haven't seen before - that the number of uninsured is controversial. You branched it out, I branched it out. I'm trying to be civil here.

The argument you made is unsupported. It doesn't mean you have other points - it doesn't even mean I disagree with those other points. It means that one aspect of your argument is one I don't think you made.

user-inactivated  ·  1505 days ago  ·  link  ·  

I'm definitely not the first one to ask the question. This article is a pretty good explanation of the problem. And there's no great answer right now. There are too many variables to credit the ACA with everyone insured now that wasn't then in any estimate.

I like my source, which you dismiss, simply because it doesn't come from the Obama Administration which wrote, supported, and had to defend the Affordable Care Act. They also had a history of greatly over estimating the amount of additonal insured going back to 2011 when they said ACA would cover 32 million people.

The source I chose comes from Goldman Sachs who stake their company's financial well-being on being objective and honest. And they certinaly have a bias, but when you combine that bias with the administration's is where we have to be subjective.

I do find your tone to be condescending, and I don't like being spoken to like that. Maybe it's the tone of the internet, and you don't mean to do it, but you come off as very know-it-all. You basically told me to behave the way you like when you threatened to block/mute me again. If you feel like you need to block me beacuse I'm the type to address that directly, that's certainly your right.

snoodog  ·  1504 days ago  ·  link  ·  

    I do find your tone to be condescending, and I don't like being spoken to like that. Maybe it's the tone of the internet, and you don't mean to do it, but you come off as very know-it-all. You basically told me to behave the way you like when you threatened to block/mute me again. If you feel like you need to block me beacuse I'm the type to address that directly, that's certainly your right.

That's just the way he always acts. Any sources that contradict his are immediately dismissed and if he can't come up with counter sources he will just hit you with anecdotal evidence that you can't address. Somewhere in the middle there will be a threat of muting and usually the last post or 2 are thinly veiled personal attacks.

The guy has an encyclopedia worth of knowledge so it's interesting to read his posts but I've found that it's not worth the emotional effort to engage with him since the discussion always gets uncivil.

kleinbl00  ·  1505 days ago  ·  link  ·  

Sweet merciful jesus, dude, leave the healthcare bullshit aside for a minute. I'm trying to be polite to you. Why don't you try the same for me?