12 ms·

I didn't claim anything of the sort. I was just saying the current system is full of moral hazards and hardly market based.

emodendroket 9y ago
I contend that the United States is the closest to an unregulated free-market system of any country in the OECD. It seems to me that if having a totally free market is a "cure-all," then a more free market ought to be a "cure-some," and yet we observe the opposite. Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.
- humanrebar 9y ago
  I don't know why people keep setting up false equivalences and false dichotomies in these discussions. Just because single-payer systems are not market based doesn't mean other systems are. > Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to. First "euphemism" implies some ulterior motive. I don't think people are trying to make people poorer. Hanlon's Razor would have us presume everyone at least thinks they have a mostly good idea. Next, if people were somehow using their own money, they'd also have the option of choosing something 10 or 20 percent more affordable, keeping the difference for other valuable things, like paying off a house, paying for grandkids' college, buying those plane tickets to see their cousins, etc. The reason there is no downward pressure to save on individual things (even predictable, non-emergency things like deviated septums) is because there's no best viable alternative. We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.
  - emodendroket 9y ago
    I don't think we need to posit a mustache-twirling villain here. They call it "skin in the game" because the idea, stated in plain terms, wouldn't be popular. If you strip away all the performative outrage that was the big "revelation" of John Gruber talking about why they started calling the individual mandate in Obamacare a "fine" rather than a "tax"; why wouldn't the same logic apply here? But don't take my word for it; here's the Rand Corporation offering a studiously even-handed assessment and giving a definition of the term matching the one I suggested: https://www.rand.org/pubs/research_briefs/RB9672/index1.html https://www.rand.org/pubs/research_briefs/RB9672/index1.html > These plans are intended to give consumers more "skin in the game" — that is, to make them responsible for a greater share of spending. Proponents of this approach contend that consumers in such plans will have more incentive to make prudent, cost-conscious decisions about using health care, which, in turn, should drive down overall health care costs. Critics, however, have voiced concerns that consumers lack information needed to reduce spending without reducing quality of care. --- > We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work. Well, first of all, that's false, in the sense that, increasingly, deductibles are substantial (a few thousand, at least), co-pays are higher, and co-insurance (where it's difficult to even predict what you'll owe) is becoming more common. Almost nobody has a plan where they don't have to pay something for medical care. But besides that, maybe in your scenario someone decides to lose weight. But let's think of another scenario. I start to experience some pain but I haven't really got the money for the doctor's visit. I decide I can tough it out. I keep doing this until the pain is truly unbearable and then I go to the doctor and find out I'm terminally ill and I waited too long to be treated. Or I forego preventative care and miss an opportunity to catch and treat cancer early. There aren't outlandish scenarios; they're the result of a system where patients have to shoulder more of the cost of care out-of-pocket, especially when combined with a state of affairs where a great many Americans do not have the savings to pay an unexpected expense of a few hundred dollars out-of-pocket.
    - humanrebar 9y ago
      > There aren't outlandish scenarios No. They are just cherry picked. There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors. Single payer doesn't solve that. They just have an unelected government official saying no. And the patient doesn't benefit in that case. I haven't heard any reply about the moral hazards of turning healthcare decisions into lobbying efforts. Do we not think the well-connected and otherwise favored will still benefit over people in poverty? I'm skeptical.
      - emodendroket 9y ago
        I don't see "not benefiting from ignoring your doctor's advice" as a problem that needs to be "solved." If you are concerned about doctors recommending unnecessary procedures I'd recommend a move away from the fee-for-service model. Patients aren't the party equipped to make the distinction.
        humanrebar 9y ago
        > ...not benefiting from ignoring your doctor's advice Who wants doctors out of the loop? I want them more in the loop. Doctor-patient relationships don't work that way. If they did, we wouldn't have people getting illicit prescriptions from doctors. Doctors, surprise, do listen to their patients wishes and accommodate them when they're OK with what the patient wants. Doctors should be advising us, "Here are your options (with prices). What do you want to do?" One option on the table for "laceration on your back" should be "have an uglier scar and give a big check to your son as a wedding present". Right now, with good insurance, there's no incentive not to treat you like an underwear model that needs scar-free skin and do experimental scar-lightening UV treatments. If a procedure (or doing nothing) is foolish, of course good doctors won't put that on the table. But single payer doesn't have doctors and patients making these decisions. They would instead look at a pre-determined schedule of options as handed down from the Bureau Of Wellness. Maybe, because of lobbying and political infighting, "uglier scar" is the only option. "Check for my engaged son" certainly isn't on the schedule.
  - dredmorbius 9y ago
    Maybe the truth is that things don't work as they're "supposed to". Could it be that the model is wrong?

emodendroket 9y ago

I contend that the United States is the closest to an unregulated free-market system of any country in the OECD. It seems to me that if having a totally free market is a "cure-all," then a more free market ought to be a "cure-some," and yet we observe the opposite. Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.

humanrebar 9y ago
I don't know why people keep setting up false equivalences and false dichotomies in these discussions. Just because single-payer systems are not market based doesn't mean other systems are. > Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to. First "euphemism" implies some ulterior motive. I don't think people are trying to make people poorer. Hanlon's Razor would have us presume everyone at least thinks they have a mostly good idea. Next, if people were somehow using their own money, they'd also have the option of choosing something 10 or 20 percent more affordable, keeping the difference for other valuable things, like paying off a house, paying for grandkids' college, buying those plane tickets to see their cousins, etc. The reason there is no downward pressure to save on individual things (even predictable, non-emergency things like deviated septums) is because there's no best viable alternative. We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.
- emodendroket 9y ago
  I don't think we need to posit a mustache-twirling villain here. They call it "skin in the game" because the idea, stated in plain terms, wouldn't be popular. If you strip away all the performative outrage that was the big "revelation" of John Gruber talking about why they started calling the individual mandate in Obamacare a "fine" rather than a "tax"; why wouldn't the same logic apply here? But don't take my word for it; here's the Rand Corporation offering a studiously even-handed assessment and giving a definition of the term matching the one I suggested: https://www.rand.org/pubs/research_briefs/RB9672/index1.html https://www.rand.org/pubs/research_briefs/RB9672/index1.html > These plans are intended to give consumers more "skin in the game" — that is, to make them responsible for a greater share of spending. Proponents of this approach contend that consumers in such plans will have more incentive to make prudent, cost-conscious decisions about using health care, which, in turn, should drive down overall health care costs. Critics, however, have voiced concerns that consumers lack information needed to reduce spending without reducing quality of care. --- > We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work. Well, first of all, that's false, in the sense that, increasingly, deductibles are substantial (a few thousand, at least), co-pays are higher, and co-insurance (where it's difficult to even predict what you'll owe) is becoming more common. Almost nobody has a plan where they don't have to pay something for medical care. But besides that, maybe in your scenario someone decides to lose weight. But let's think of another scenario. I start to experience some pain but I haven't really got the money for the doctor's visit. I decide I can tough it out. I keep doing this until the pain is truly unbearable and then I go to the doctor and find out I'm terminally ill and I waited too long to be treated. Or I forego preventative care and miss an opportunity to catch and treat cancer early. There aren't outlandish scenarios; they're the result of a system where patients have to shoulder more of the cost of care out-of-pocket, especially when combined with a state of affairs where a great many Americans do not have the savings to pay an unexpected expense of a few hundred dollars out-of-pocket.
  - humanrebar 9y ago
    > There aren't outlandish scenarios No. They are just cherry picked. There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors. Single payer doesn't solve that. They just have an unelected government official saying no. And the patient doesn't benefit in that case. I haven't heard any reply about the moral hazards of turning healthcare decisions into lobbying efforts. Do we not think the well-connected and otherwise favored will still benefit over people in poverty? I'm skeptical.
    - emodendroket 9y ago
      I don't see "not benefiting from ignoring your doctor's advice" as a problem that needs to be "solved." If you are concerned about doctors recommending unnecessary procedures I'd recommend a move away from the fee-for-service model. Patients aren't the party equipped to make the distinction.
      - humanrebar 9y ago
        > ...not benefiting from ignoring your doctor's advice Who wants doctors out of the loop? I want them more in the loop. Doctor-patient relationships don't work that way. If they did, we wouldn't have people getting illicit prescriptions from doctors. Doctors, surprise, do listen to their patients wishes and accommodate them when they're OK with what the patient wants. Doctors should be advising us, "Here are your options (with prices). What do you want to do?" One option on the table for "laceration on your back" should be "have an uglier scar and give a big check to your son as a wedding present". Right now, with good insurance, there's no incentive not to treat you like an underwear model that needs scar-free skin and do experimental scar-lightening UV treatments. If a procedure (or doing nothing) is foolish, of course good doctors won't put that on the table. But single payer doesn't have doctors and patients making these decisions. They would instead look at a pre-determined schedule of options as handed down from the Bureau Of Wellness. Maybe, because of lobbying and political infighting, "uglier scar" is the only option. "Check for my engaged son" certainly isn't on the schedule.
- dredmorbius 9y ago
  Maybe the truth is that things don't work as they're "supposed to". Could it be that the model is wrong?