4 ms·

I'd feel more able to agree with you if the NYT didn't carry water for some whoppers ("you can keep you doctor", "insurers will compete for your business", etc.

I'd feel more able to agree with you if the NYT didn't carry water for some whoppers ("you can keep you doctor", "insurers will compete for your business", etc.) back when the ACA was passed in the first place.

specialist 9y ago
Insurer's response to ACA reminds me of a Frank & Ernest comic, which I can't find right now, sorry: Two USPS workers. Package label says "Do not bend, fold, mutilate." One says to the other "Doesn't say anything about crumple!" Har har har. --- I had high hopes for ACA. I believed the 15% medical loss ratio was the poison pill that would eventually drive insurers out of business, and therefore lead to Medicare for All. For comparison, Medicare's is under 5%, meaning 95 cents for every dollar spent goes to patient care, vs coke and prostitutes for the execs. Silly me. There's no set of rules that can't be broken, gamed. So now I'm for dozing it all down and rebuilding with universal coverage, single payer, using the capitation model (reward wellness vs fee for service). No more incrementalism. Just do it. --- Aside: Mid 2000s, my team created, implemented, supported 5 regional health information exchanges (eg BHIX). It was clear then, to everyone in healthcare IT, that we were pushing cooked noodles across hot pavement. Since then, it's only gotten worse. Overhead continues to grow geometrically, due to things like ICD-10 and meaningful care, without nudging the patient care (outcomes) needle one bit. I can't explain it. I just read about cost disease. It seems to explain rising costs, but I don't understand the mechanism, or what to do about it. https://en.wikipedia.org/wiki/Baumol%27s_cost_disease https://en.wikipedia.org/wiki/Baumol%27s_cost_disease And this book blew my mind: "The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy" by David Graeber http://amzn.to/2mi169U http://amzn.to/2mi169U
- koolba 9y ago
  Putting any kind of cap on efficiency of a middle man is asinine. The only outcome is the realization that the only way to make more profits is increase the top line number (i.e. Premiums).
  - specialist 9y ago
    Our government has capped APRs for credit cards. Then, banks added fees, reduced services. Then govt capped fees. Whackamole. Is this a legit analogy? If so, is either side wrong? How would you handle it, if you were King? My only notion for healthcare is to change the incentives. Reward wellness vs treat disease.
    - humanrebar 9y ago
      > My only notion for healthcare is to change the incentives. That's only a recipe for lobbying over what bureaucrats designate "wellness" and "disease". The best way to fix healthcare is to cut out more middlemen. The person whose health is being cared for (or their loved ones) needs to decide when another $10k scan or $65k pill regimen is worth it compared to using the cash to pay off their (grand)kids' student loans. If all of this is filtered through insurers, lawyers, and government officials, there is incentives to meet budgets and increase revenue, but there's no win for the actual people and families all this is supposed to be taking care of.
      - specialist 9y ago
        Wellness is easily measured. Life expectancy, sick days, patient surveys. The fight happens during rationing (bureaucratic triage). So you'd eliminate pharmacy benefit management companies? https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Litigation_and_controversies https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Li... Or are you saying eliminate insurers (insurance) altogether?
        humanrebar 9y ago
        The government can't be rational about what a balanced meal looks like or how tomatoes (fruit? veg?) fit in the picture. There's a reason food lobbying groups exist. > Or are you saying eliminate insurers (insurance) altogether? I'm not saying there's an easy answer, but as long as all health transactions are paying for one party's health with another party's money, we'll have bad outcomes. If the problem is that it's expensive to live, then let's talk about that problem (negative income tax credit, minimum income, optimize for cost of living, etc.) instead of trying to bureaucracy (private or public) our way into utopia.
- coredog64 9y ago
  HHS doesn't actually pay medical costs with that 95%. They take a 5% cut for their own overhead and then turn around and pay a group of private insurance companies to provide coverage with the rest.
  - aladoc99 9y ago
    I think the 5% includes the administrative cost of the third-party administrators as well as HHS itself. The 95% is payments to hospitals, doctors, pharmacies, etc.
- mason240 9y ago
  I believe the ACA itself was a poison pill that would make the system so inefficient to drive it to collapse and bring about single payer. The failure of Republicans to implement an alternative has pretty much guaranteed it.
  - theseatoms 9y ago
    I think this is right. If not a deliberate poison pill, implementation of the ACA was a strong "foot in the door" technique for those who want single payer. Though, even before the ACA, the government is deeply involved in the system (employer based tax incentives, Medicare, etc) I don't find that surprising though. I think Obama himself said that ACA was just a start and would have to be revisited. (Citation needed, I know.) What's amazing is just how bad conservatives have been at articulating the free market case for health care and insurance.
  - YPCrumble 9y ago
    I'm hoping Donald Trump is the poison pill that will bring about the Progressive movement.
    - Karunamon 9y ago
      He's a poison pill alright, but I'm not sure who's going to feel the poison. He's either the end of the Democrat establishment (the election and post-election hysterics are unheard of in my lifetime), or the end of the Republican establishment (if he crashes and burns as bad as certain circles think he will).
  - sp332 9y ago
    Healthcare costs grew under the ACA, but the rate of growth slowed. I don't think it was more inefficient than continuing with the old system would have been. Right now though they're working to defund as many parts of the ACA as they can, so even if it doesn't get repealed, it's going to be in bad shape from now on.
- aladoc99 9y ago
  It's important to recognize that capitation provides a powerful economic incentive to provide as little care as possible. Every pill, X-ray, MRI, or surgery comes straight out of the insurer's bottom line. You'd like to see an allergist/rheumatologist/orthopedic surgeon? How about the thirty-third of Nevember? Instead you can talk to a high-schooler in another country with a wellness script.
untog 9y ago
I don't see how reporting a politican's comments were "carrying water". At the time Obama said that you could keep your doctor I don't think there was any way to disprove his statement, because the ACA hadn't been enacted yet.
cwyers 9y ago
I'm not carrying water for the ACA, which I think is not-very-good law, and I remember back when even congressional Democrats thought it was "the stupid compromise we can get Max Baucus and Joe Lieberman to allow to pass the Senate" and not a hill worth dying on.

specialist 9y ago

Insurer's response to ACA reminds me of a Frank & Ernest comic, which I can't find right now, sorry: Two USPS workers. Package label says "Do not bend, fold, mutilate." One says to the other "Doesn't say anything about crumple!" Har har har. --- I had high hopes for ACA. I believed the 15% medical loss ratio was the poison pill that would eventually drive insurers out of business, and therefore lead to Medicare for All. For comparison, Medicare's is under 5%, meaning 95 cents for every dollar spent goes to patient care, vs coke and prostitutes for the execs. Silly me. There's no set of rules that can't be broken, gamed. So now I'm for dozing it all down and rebuilding with universal coverage, single payer, using the capitation model (reward wellness vs fee for service). No more incrementalism. Just do it. --- Aside: Mid 2000s, my team created, implemented, supported 5 regional health information exchanges (eg BHIX). It was clear then, to everyone in healthcare IT, that we were pushing cooked noodles across hot pavement. Since then, it's only gotten worse. Overhead continues to grow geometrically, due to things like ICD-10 and meaningful care, without nudging the patient care (outcomes) needle one bit. I can't explain it. I just read about cost disease. It seems to explain rising costs, but I don't understand the mechanism, or what to do about it. https://en.wikipedia.org/wiki/Baumol%27s_cost_disease https://en.wikipedia.org/wiki/Baumol%27s_cost_disease And this book blew my mind: "The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy" by David Graeber http://amzn.to/2mi169U http://amzn.to/2mi169U

koolba 9y ago
Putting any kind of cap on efficiency of a middle man is asinine. The only outcome is the realization that the only way to make more profits is increase the top line number (i.e. Premiums).
- specialist 9y ago
  Our government has capped APRs for credit cards. Then, banks added fees, reduced services. Then govt capped fees. Whackamole. Is this a legit analogy? If so, is either side wrong? How would you handle it, if you were King? My only notion for healthcare is to change the incentives. Reward wellness vs treat disease.
  - humanrebar 9y ago
    > My only notion for healthcare is to change the incentives. That's only a recipe for lobbying over what bureaucrats designate "wellness" and "disease". The best way to fix healthcare is to cut out more middlemen. The person whose health is being cared for (or their loved ones) needs to decide when another $10k scan or $65k pill regimen is worth it compared to using the cash to pay off their (grand)kids' student loans. If all of this is filtered through insurers, lawyers, and government officials, there is incentives to meet budgets and increase revenue, but there's no win for the actual people and families all this is supposed to be taking care of.
    - specialist 9y ago
      Wellness is easily measured. Life expectancy, sick days, patient surveys. The fight happens during rationing (bureaucratic triage). So you'd eliminate pharmacy benefit management companies? https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Litigation_and_controversies https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Li... Or are you saying eliminate insurers (insurance) altogether?
      - humanrebar 9y ago
        The government can't be rational about what a balanced meal looks like or how tomatoes (fruit? veg?) fit in the picture. There's a reason food lobbying groups exist. > Or are you saying eliminate insurers (insurance) altogether? I'm not saying there's an easy answer, but as long as all health transactions are paying for one party's health with another party's money, we'll have bad outcomes. If the problem is that it's expensive to live, then let's talk about that problem (negative income tax credit, minimum income, optimize for cost of living, etc.) instead of trying to bureaucracy (private or public) our way into utopia.
coredog64 9y ago
HHS doesn't actually pay medical costs with that 95%. They take a 5% cut for their own overhead and then turn around and pay a group of private insurance companies to provide coverage with the rest.
- aladoc99 9y ago
  I think the 5% includes the administrative cost of the third-party administrators as well as HHS itself. The 95% is payments to hospitals, doctors, pharmacies, etc.
mason240 9y ago
I believe the ACA itself was a poison pill that would make the system so inefficient to drive it to collapse and bring about single payer. The failure of Republicans to implement an alternative has pretty much guaranteed it.
- theseatoms 9y ago
  I think this is right. If not a deliberate poison pill, implementation of the ACA was a strong "foot in the door" technique for those who want single payer. Though, even before the ACA, the government is deeply involved in the system (employer based tax incentives, Medicare, etc) I don't find that surprising though. I think Obama himself said that ACA was just a start and would have to be revisited. (Citation needed, I know.) What's amazing is just how bad conservatives have been at articulating the free market case for health care and insurance.
- YPCrumble 9y ago
  I'm hoping Donald Trump is the poison pill that will bring about the Progressive movement.
  - Karunamon 9y ago
    He's a poison pill alright, but I'm not sure who's going to feel the poison. He's either the end of the Democrat establishment (the election and post-election hysterics are unheard of in my lifetime), or the end of the Republican establishment (if he crashes and burns as bad as certain circles think he will).
- sp332 9y ago
  Healthcare costs grew under the ACA, but the rate of growth slowed. I don't think it was more inefficient than continuing with the old system would have been. Right now though they're working to defund as many parts of the ACA as they can, so even if it doesn't get repealed, it's going to be in bad shape from now on.
aladoc99 9y ago
It's important to recognize that capitation provides a powerful economic incentive to provide as little care as possible. Every pill, X-ray, MRI, or surgery comes straight out of the insurer's bottom line. You'd like to see an allergist/rheumatologist/orthopedic surgeon? How about the thirty-third of Nevember? Instead you can talk to a high-schooler in another country with a wellness script.

untog 9y ago

I don't see how reporting a politican's comments were "carrying water". At the time Obama said that you could keep your doctor I don't think there was any way to disprove his statement, because the ACA hadn't been enacted yet.

cwyers 9y ago

I'm not carrying water for the ACA, which I think is not-very-good law, and I remember back when even congressional Democrats thought it was "the stupid compromise we can get Max Baucus and Joe Lieberman to allow to pass the Senate" and not a hill worth dying on.