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I think you've answered a question you'd like to answer instead of one you don't: WHY is healthcare in this country SO EXPENSIVE? The way to make care availabl

by Nrsolis 10y ago

I think you've answered a question you'd like to answer instead of one you don't: WHY is healthcare in this country SO EXPENSIVE? The way to make care available is to drive down costs. We haven't done a single thing with the ACA to improve the affordability of care, we've just made the un-affordability a problem borne by the people who were already doing a good job of taking care of themselves. That's not a scalable solution. The ACA got us a lot of short-term benefit for a small group of people but set in motion a chain of events that will only drive UP costs while driving affordability down. And I'd like to argue that until we do something to improve the market dynamics of healthcare we are very likely to see this sort of thing continue to get worse until it's so unsustainable that it's like trying to legislate away the force of gravity. One thing I'd like to see in any future version of ACA reform is RIGOROUS price transparency by healthcare providers. It should be absolutely illegal for any healthcare provider to conceal, obfuscate, or otherwise obstruct the price discovery mechanism of the market. Even if you argue that consumers aren't the best people to decide what services are necessary or needed, they can rely on the advice of trusted advisors and popular understanding to shop for healthcare at providers known for offering good value. SO MUCH of health care isn't of the "emergent" kind but the kind that is for chronic issues that are the result of unhealthy living or plain bad genetic luck. We need to redouble our efforts to drive those costs of care down and start paying for results and not treatment. Paying for treatment encourages overconsumption. Paying for outcomes encourages optimizing for cures.

krupan 10y ago
Well said. Can we also work on the supply of medical care? We keep giving more and more people insurance which increases demand without doing anything to increase supply and then wonder why prices go up.
tunesmith 10y ago
Your second paragraph is not even close to true - if you do more research on the ACA you'll find that it does all kinds of things to try and improve the affordability of care, a lot of which has made real improvements. Incentives against fee-for-service, quality-of-care rules, medicare/medicaid rules, there's just a ton of that stuff in the ACA. The stuff in your last paragraph is directly addressed by many parts of the ACA. And, more can definitely be done, including price transparency etc. These things tend to be supported by Democrats and opposed by Republicans.
- Nrsolis 10y ago
  I think you should post some links to relevant sections of the ACA and show me where they take specific actions to drive down costs. I will tell you that I've seen scant evidence that it's working. A wishlist of initiatives isn't a plan for action that drives down costs. Allowing Medicare to NEGOTIATE prices for drugs is a plan to drive down costs. The insurance companies wanted to GROW the per-capita spend on healthcare. That benefited them. It's really really unclear if it benefited the public right now. Forcing people into a market they don't want to be in isn't reform. The way to solve this problem is to make being a part of the market ATTRACTIVE. IMHO we really missed an opportunity to affect behaviors. For one thing, Romneycare incentivized people to skip insurance until they needed it. That was a recipe for adverse selection. The way to help this is to provide incentives for people to get in WAY EARLY and pay for their OWN care long before they may need it while also providing a measurable benefit to those who get in early right away. People are capable of responding to incentives and I'm convinced that there exists a Nash equilibrium in healthcare that helps everybody win. Remember, the same people who gave you "the Internet is not a truck" are the same people you're expecting to solve healthcare affordability. Think about that.
  - ubernostrum 10y ago
    I work for a company which operates in the Medicare Advantage space. A provision of the ACA sets a minimum medical loss ratio for us. In simpler terms: it puts a legal cap on our profit margin, by requiring a minimum percentage of the money we take in to be spent on benefits to our members (such as paying their claims). That is almost certainly going to get repealed.
    - Nrsolis 10y ago
      In that scenario, are your interests served more by spending via medicare increasing or going down? If your incentive is to maximize the absolute amount of actual profit you earn and the ONLY way you can do that is to push more money towards healthcare providers, then what do you think will actually occur? Because once you have achieved that spend level on provider care, you're in the clear. The ONLY way for you to increase profit is to ensure that more procedures happen.
sanderjd 10y ago
Unless medical care is cheap enough for everyone to always afford all the care they might require with the cash in their pockets or the money in their checking accounts, I believe my fundamental question is relevant. Since some medical care currently, and for the forseeable future, requires the time of extremely smart, talented, and highly-trained individuals, I don't believe it's possible to make it that cheap. I agree with everything else you said though. Costs are too high and are a major reason this is so hard to solve and price transparency is a big part of the problem. A related (because it distorts the market in a similar way) problem is that most people don't see the true cost of their insurance, because they get it as a benefit from their employer. I would be highly in favor of any credible attempts to fix these issues. But that's not what I've been hearing from the party that's about to be completely in power.

by Nrsolis 10y ago

krupan 10y ago

Well said. Can we also work on the supply of medical care? We keep giving more and more people insurance which increases demand without doing anything to increase supply and then wonder why prices go up.

tunesmith 10y ago

Your second paragraph is not even close to true - if you do more research on the ACA you'll find that it does all kinds of things to try and improve the affordability of care, a lot of which has made real improvements. Incentives against fee-for-service, quality-of-care rules, medicare/medicaid rules, there's just a ton of that stuff in the ACA. The stuff in your last paragraph is directly addressed by many parts of the ACA. And, more can definitely be done, including price transparency etc. These things tend to be supported by Democrats and opposed by Republicans.

Nrsolis 10y ago
I think you should post some links to relevant sections of the ACA and show me where they take specific actions to drive down costs. I will tell you that I've seen scant evidence that it's working. A wishlist of initiatives isn't a plan for action that drives down costs. Allowing Medicare to NEGOTIATE prices for drugs is a plan to drive down costs. The insurance companies wanted to GROW the per-capita spend on healthcare. That benefited them. It's really really unclear if it benefited the public right now. Forcing people into a market they don't want to be in isn't reform. The way to solve this problem is to make being a part of the market ATTRACTIVE. IMHO we really missed an opportunity to affect behaviors. For one thing, Romneycare incentivized people to skip insurance until they needed it. That was a recipe for adverse selection. The way to help this is to provide incentives for people to get in WAY EARLY and pay for their OWN care long before they may need it while also providing a measurable benefit to those who get in early right away. People are capable of responding to incentives and I'm convinced that there exists a Nash equilibrium in healthcare that helps everybody win. Remember, the same people who gave you "the Internet is not a truck" are the same people you're expecting to solve healthcare affordability. Think about that.
- ubernostrum 10y ago
  I work for a company which operates in the Medicare Advantage space. A provision of the ACA sets a minimum medical loss ratio for us. In simpler terms: it puts a legal cap on our profit margin, by requiring a minimum percentage of the money we take in to be spent on benefits to our members (such as paying their claims). That is almost certainly going to get repealed.
  - Nrsolis 10y ago
    In that scenario, are your interests served more by spending via medicare increasing or going down? If your incentive is to maximize the absolute amount of actual profit you earn and the ONLY way you can do that is to push more money towards healthcare providers, then what do you think will actually occur? Because once you have achieved that spend level on provider care, you're in the clear. The ONLY way for you to increase profit is to ensure that more procedures happen.

sanderjd 10y ago

Unless medical care is cheap enough for everyone to always afford all the care they might require with the cash in their pockets or the money in their checking accounts, I believe my fundamental question is relevant. Since some medical care currently, and for the forseeable future, requires the time of extremely smart, talented, and highly-trained individuals, I don't believe it's possible to make it that cheap. I agree with everything else you said though. Costs are too high and are a major reason this is so hard to solve and price transparency is a big part of the problem. A related (because it distorts the market in a similar way) problem is that most people don't see the true cost of their insurance, because they get it as a benefit from their employer. I would be highly in favor of any credible attempts to fix these issues. But that's not what I've been hearing from the party that's about to be completely in power.