5 ms·

Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a ba

Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a basic income. (Which is not to say that I disagree with you, though I do think that there are actually three different cost categories of health care: 1. Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs. 2. One-time catastrophes, like "I broke my arm" or "I got pneumonia." Probably best dealt with as insurance. 3. Long-term or lifelong large expenses, like "I have HIV" or "I have MS." Probably best dealt with as a government program. But then you'll have a lot of problems with the boundary cases.)

dragonwriter 10y ago
> Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a basic income. We already have a national individual mandate for health insurance with specific coverage rules which has made decisions about this; essentially, a mature BI would cover expected out-of-pocket costs plus insurance premiums in that system. (That's not to say further reform of that system isn't possible or desirable, with or without BI, just that, given the existing system, there seems to be a fairly natural way that healthcare within that system fits into BI.)
- aetherson 10y ago
  Sorry, I misunderstood your previous comment to mean that you thought we should go to an India-like "out of pocket" system plus (optional) health insurance to handle catastrophic costs. Rereading, your intent is clear. (Not sure why I jumped to that conclusion, except that perhaps a basic income system appeals to the same economic minimalism that an out-of-pocket health cost system does.)
bryondowd 10y ago
Just want to point out that making routine/preventative care an out-of-pocket cost is probably one of the worst things you can do. I expect there's a reason many companies emphasize and encourage their employees take advantage of 100% free preventive care under their insurance plans. You can save a ton of money later by catching and treating issues early, and even a small personal cost can encourage people to ignore warning signs and not seek aid until the problem has become severe and expensive.
- aetherson 10y ago
  Yeah, this is deeply off-topic, but my reading of the evidence is that preventative or diagnostic care is typically not cost-effective or even outcome-enhancing, with a few specific exceptions like vaccinations.
  - bryondowd 10y ago
    Interesting. I'd love to see support for this view. Everything I've heard suggests the opposite. Especially if you consider worker productivity in addition to healthcare costs.
    - aetherson 10y ago
      http://www.nejm.org/doi/full/10.1056/NEJMp0708558 http://www.nejm.org/doi/full/10.1056/NEJMp0708558 http://www.reuters.com/article/us-preventive-economics-idUSBRE90S05M20130129 http://www.reuters.com/article/us-preventive-economics-idUSB... http://www.statcan.gc.ca/pub/82-003-x/2015012/article/14295-eng.htm http://www.statcan.gc.ca/pub/82-003-x/2015012/article/14295-... http://www.thehoopsnews.com/effectiveness-of-mammograms-vastly-overestimated-study-6622 http://www.thehoopsnews.com/effectiveness-of-mammograms-vast... It's a complex subject, and a few articles aren't the final word one way or the other. My opinion is based on various things I've read over the past couple of decades (most of which I can't summon up right now) and conversations with various medical professionals in my family and social circle, and my overall worldview (as anyone's must be).
      - bryondowd 10y ago
        Ok, this is interesting. Some of this fits my intuitions, and some was a surprise to me, so yes, this does modify my view, but only slightly. It seems there are preventative measures that are cost effective, and there are others that are not. So really, this indicates a need to determine a threshold. Perhaps we determine that we can afford to pay up to $50,000 per QALY, and cover any care that falls within that limit. So, we'd have coverage based on its efficiency rather than whether it is considered preventative or treatment or maintenance. The idea being to get the maximum amount of healthy years of life out of whatever amount of money we as society are willing to put toward healthcare. This could also be extended to programs outside of direct care, like some of those articles suggest, which encourage and support healthy activity in a way that still falls within the $/QALY target. Of course, I expect it would be a bear to fairly study every possible treatment and program to determine its efficiency, especially factoring in a changing environment which is bound to change the efficiency of any given treatment from year to year. Still, at a minimum, we should be grabbing those low-hanging fruits, where we can gain healthy years for a very low cost.
wutbrodo 10y ago
> 1. Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs. This is a pretty terrible idea. Even programs in the current day that are trying to make consumers feel their healthcare costs (like HSAs and their required high-deductible PPO plans) often or always cover preventative care at 100%. Preventative care is precisely the kind of care that people are most likely to skip to save on some money, and at the system-level this just means much more costly healthcare. Regardless of how you structure your healthcare system, increasing the cost of the actual care itself is a horrible idea.
stordoff 10y ago
> Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs. This seems like a terrible idea. If someone, for example, notices a new mole, they are much less likely to get it checked out if it is an out-of-pocket expense. Obviously, most of the time it'll be fine, but it could also be skin cancer that was easily treatable but has now metastasised and will be hugely expensive to treat.

dragonwriter 10y ago

> Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a basic income. We already have a national individual mandate for health insurance with specific coverage rules which has made decisions about this; essentially, a mature BI would cover expected out-of-pocket costs plus insurance premiums in that system. (That's not to say further reform of that system isn't possible or desirable, with or without BI, just that, given the existing system, there seems to be a fairly natural way that healthcare within that system fits into BI.)

aetherson 10y ago
Sorry, I misunderstood your previous comment to mean that you thought we should go to an India-like "out of pocket" system plus (optional) health insurance to handle catastrophic costs. Rereading, your intent is clear. (Not sure why I jumped to that conclusion, except that perhaps a basic income system appeals to the same economic minimalism that an out-of-pocket health cost system does.)

bryondowd 10y ago

Just want to point out that making routine/preventative care an out-of-pocket cost is probably one of the worst things you can do. I expect there's a reason many companies emphasize and encourage their employees take advantage of 100% free preventive care under their insurance plans. You can save a ton of money later by catching and treating issues early, and even a small personal cost can encourage people to ignore warning signs and not seek aid until the problem has become severe and expensive.

aetherson 10y ago
Yeah, this is deeply off-topic, but my reading of the evidence is that preventative or diagnostic care is typically not cost-effective or even outcome-enhancing, with a few specific exceptions like vaccinations.
- bryondowd 10y ago
  Interesting. I'd love to see support for this view. Everything I've heard suggests the opposite. Especially if you consider worker productivity in addition to healthcare costs.
  - aetherson 10y ago
    http://www.nejm.org/doi/full/10.1056/NEJMp0708558 http://www.nejm.org/doi/full/10.1056/NEJMp0708558 http://www.reuters.com/article/us-preventive-economics-idUSBRE90S05M20130129 http://www.reuters.com/article/us-preventive-economics-idUSB... http://www.statcan.gc.ca/pub/82-003-x/2015012/article/14295-eng.htm http://www.statcan.gc.ca/pub/82-003-x/2015012/article/14295-... http://www.thehoopsnews.com/effectiveness-of-mammograms-vastly-overestimated-study-6622 http://www.thehoopsnews.com/effectiveness-of-mammograms-vast... It's a complex subject, and a few articles aren't the final word one way or the other. My opinion is based on various things I've read over the past couple of decades (most of which I can't summon up right now) and conversations with various medical professionals in my family and social circle, and my overall worldview (as anyone's must be).
    - bryondowd 10y ago
      Ok, this is interesting. Some of this fits my intuitions, and some was a surprise to me, so yes, this does modify my view, but only slightly. It seems there are preventative measures that are cost effective, and there are others that are not. So really, this indicates a need to determine a threshold. Perhaps we determine that we can afford to pay up to $50,000 per QALY, and cover any care that falls within that limit. So, we'd have coverage based on its efficiency rather than whether it is considered preventative or treatment or maintenance. The idea being to get the maximum amount of healthy years of life out of whatever amount of money we as society are willing to put toward healthcare. This could also be extended to programs outside of direct care, like some of those articles suggest, which encourage and support healthy activity in a way that still falls within the $/QALY target. Of course, I expect it would be a bear to fairly study every possible treatment and program to determine its efficiency, especially factoring in a changing environment which is bound to change the efficiency of any given treatment from year to year. Still, at a minimum, we should be grabbing those low-hanging fruits, where we can gain healthy years for a very low cost.

wutbrodo 10y ago

> 1. Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs. This is a pretty terrible idea. Even programs in the current day that are trying to make consumers feel their healthcare costs (like HSAs and their required high-deductible PPO plans) often or always cover preventative care at 100%. Preventative care is precisely the kind of care that people are most likely to skip to save on some money, and at the system-level this just means much more costly healthcare. Regardless of how you structure your healthcare system, increasing the cost of the actual care itself is a horrible idea.

stordoff 10y ago

> Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs. This seems like a terrible idea. If someone, for example, notices a new mole, they are much less likely to get it checked out if it is an out-of-pocket expense. Obviously, most of the time it'll be fine, but it could also be skin cancer that was easily treatable but has now metastasised and will be hugely expensive to treat.