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Every discussion on healthcare payment structures in this country is completely asinine. Healthcare is best managed as a risk pool. The bigger the pool, the ch

Every discussion on healthcare payment structures in this country is completely asinine. Healthcare is best managed as a risk pool. The bigger the pool, the cheaper to be in it. The biggest risk pool is everyone. Therefore, we should put everyone in a single pool. How we manage this is a separate discussion. Private, public, maybe a federally chartered non-profit like the Fed. But as long as we keep ourselves fractured into thousands of different risk pools, all these discussions about deductibles and HSAs and whatnot are just chasing our own tails.

cmuguythrow 7y ago
To be fair, this perspective does assume that people care about the health of society as a whole. If you're willing to let others get substandard care or even die, it may be more optimal for you to have your own smaller, lower-risk pool with better benefits.
- deleted 7y ago
  [deleted]
- FireBeyond 7y ago
  Right. And therein lies the rub. The US is quite possibly one of the worst in the world for "Fuck you I got mine" (until you don't got yours). And then there's the cognitive dissonance of people who might have otherwise screamed about "socialized medicine" who find themselves on the unlucky end of a diagnosis and are singing a different tune (or sometimes still singing the same tune, even as they put up a GoFundMe...). How many other countries in the world consider medical bankruptcy a thing to be accepted and tolerated?
  - rayiner 7y ago
    By contrast, would the US be able to stomach denying cutting-edge treatment because it’s too expensive, like the UK? https://www.theguardian.com/science/2017/dec/20/drug-giants-hefty-prices-nhs-vital-medication-pharma-profits https://www.theguardian.com/science/2017/dec/20/drug-giants-... That’s what makes me nervous about socialized medicine in the US. I’m absolutely in favor of universal coverage—a healthcare system that maximizes the health of the average productive person. But I worry that Americans lack the cold realism of Brits, and won’t be able to effectively control costs by denying cost-ineffective treatments.
    - FireBeyond 7y ago
      Well, that article talks about blaming Big Pharma for the costs that make it expensive, not the National Health Service. With the big pool comes big leverage. The NHS effectively said "We're not paying that much", and the pharmaceutical companies decided they'd rather be paid something. Because if someone is not getting treatment, then they're not getting those drugs. Medicare in the US does this. "This is what we are paying for this drug". The issue isn't so much this. It's that drug industry lobbies in the US will have far more sway over the politics of this than they would in the UK (or Canada, or Australia, or...). I definitely don't claim to be an expert on these things. But I have lived in the UK with the NHS, in Australia with its medical system, and now in the US. In addition to that, I've worked as a healthcare provider, and for a Health Benefits Management software company, so I'd at least like to think I have something of a varied perspective.
      - rayiner 7y ago
        The very first part of the article explains how the NHS denied coverage for certain breast cancer drugs because it was too expensive. My concern is that the Americans won’t be willing to do that. Here, you see all these articles talking about how terrible it is that families went bankrupt going out of pocket after they hit a $1 million cap. The UK wouldn’t have paid for that treatment in the first place.
        roywiggins 7y ago
        You have an admirable faith the American insurance companies don't do exactly the same thing, with much less oversight. https://www.nytimes.com/2019/02/27/obituaries/carrie-ann-lucas-dead.html https://www.nytimes.com/2019/02/27/obituaries/carrie-ann-luc... > Her family said an antibiotic Lucas needed to treat her symptoms cost about $2,000 and her insurance company denied coverage of the medicine, leading her to take a less-effective drug. Lucas, who was allergic to multiple drugs and antibiotics, had a reaction to that medication, Lee Lucas said.
        selimthegrim 7y ago
deleted 7y ago
[deleted]
pdonis 7y ago
> Healthcare is best managed as a risk pool. No, health insurance is best managed as a risk pool, which, as you say, should obviously be everyone. But much of health care is not health insurance because it doesn't deal with insurable risks. Your need to get an annual physical isn't an insurable risk. Neither is a one-time appointment with a doctor to see if your headache and runny nose is just a cold or an infection that requires antibiotics. The first isn't insurable because it's a predictable recurring cost; the second isn't because it's a routine service that shouldn't be so expensive that you can't pay it out of pocket. Health insurance should be focused on the things that are insurable risks: emergency care, hospitalization, etc. Things that aren't insurable risks, like the above, should be handled differently. But our health care system insists on treating these very different things the same, which of course is going to lead to huge inefficiencies and high costs.
- ericpauley 7y ago
  While this may make sense from the perspective of why people get insurance (to mitigate a catastrophic loss), it doesn't consider the insurer's incentives. No insurance company will want to underwrite a plan that doesn't bundle routine services, since those clearly reduce risk of complications down the road. A yearly checkup is cheap compared to missing a disease and letting it get worse.
  - pdonis 7y ago
    > No insurance company will want to underwrite a plan that doesn't bundle routine services, since those clearly reduce risk of complications down the road But current plans don't require you to get routine services like an annual physical; they just cover them if you get them. That doesn't make sense if the insurer's incentives that you describe are driving the plan. Also, these incentives don't seem to be operating in other insurance markets. For example, auto insurance doesn't cover routine maintenance like oil changes or tire rotation.
    - epicureanideal 7y ago
      Maybe we should have two separate kinds of health insurance? One for true emergencies (like car accidents), and rare life threatening diseases (like cancer before 60). Another for routine things, but as others have said, routine things shouldn't be so expensive. I like the idea of structuring it like a term life insurance policy. If you die, you get money, and in some policies you even get some percentage before you die to have fun. So, if you get cancer or whatever, perhaps you'd have a pool of funds available to you to deal with the disease, and you can use that money how you want, and perhaps even keep the remainder (or a portion of it) to incentivize keeping cost down. Also, it would make sense for the pool of funds available to someone to be based on remaining years. If you get cancer when you 20 it makes sense to spend a million dollars trying to cure that. If you're 90, maybe it makes sense to treat it but not as aggressively or in as costly of ways. From the perspective of building a society that you would be willing to be in, assuming you were randomly born into that society without knowing to what parents, I still think many people would agree they'd rather spend heavily on younger people than older.
manfredo 7y ago
> Healthcare is best managed as a risk pool. The bigger the pool, the cheaper to be in it. The biggest risk pool is everyone. Therefore, we should put everyone in a single pool. No, whether or not expanding the pool raises costs depends on the cost of the added population. If 80% of the population is insured, and they consume an average of $1,000 in healthcare costs each year and the uninsured population consumes $10,000/yr then expanding the risk pool to the entire population will increase the cost of insurance. We saw this happen firsthand when we mandated that insurers take on all patients at the same cost regardless of prior conditions. The population that was added to the risk pool was more expensive than average, thus driving up the cost charged per person. Universal healthcare isn't a magic wand that makes healthcare costs go down, these plans are affordable for the average person because they are paid for by taxes which are levied at different rates depending on income. I many of these countries if you charged the cost of healthcare per person on people's post-tax income (and adding back in the tax paid for healthcare) they would be paying a greater portion of their paycheck for healthcare than most Americans. The affordability isn't solved by dumping everyone into one risk pool, it's solved by changing the way healthcare is paid for. Furthermore, most universal healthcare implementations don't put everyone in the same risk pool they tax and give citizens funds to spend on healthcare but the risk pools themselves are managed by insurance companies.
thatoneuser 7y ago
Why should we, the conscientious readers, trust your claim that you know what's best? Cuz it sounds like something that sounds good but which has no verifiable backing.
lordlimecat 7y ago
Healthcare in the states is asinine, no doubt. But when I see articles like this I have to ask, "why aren't these people making 75-100k using HSAs and FSAs"? They would eliminate many of these scenarios that people are seeing. There's the elephant in the room that many people are absolutely terrible with money, buying entertainment goods and completely skipping on savings, HSAs, etc that could prevent these media sob stories.

cmuguythrow 7y ago

To be fair, this perspective does assume that people care about the health of society as a whole. If you're willing to let others get substandard care or even die, it may be more optimal for you to have your own smaller, lower-risk pool with better benefits.

deleted 7y ago
[deleted]
FireBeyond 7y ago
Right. And therein lies the rub. The US is quite possibly one of the worst in the world for "Fuck you I got mine" (until you don't got yours). And then there's the cognitive dissonance of people who might have otherwise screamed about "socialized medicine" who find themselves on the unlucky end of a diagnosis and are singing a different tune (or sometimes still singing the same tune, even as they put up a GoFundMe...). How many other countries in the world consider medical bankruptcy a thing to be accepted and tolerated?
- rayiner 7y ago
  By contrast, would the US be able to stomach denying cutting-edge treatment because it’s too expensive, like the UK? https://www.theguardian.com/science/2017/dec/20/drug-giants-hefty-prices-nhs-vital-medication-pharma-profits https://www.theguardian.com/science/2017/dec/20/drug-giants-... That’s what makes me nervous about socialized medicine in the US. I’m absolutely in favor of universal coverage—a healthcare system that maximizes the health of the average productive person. But I worry that Americans lack the cold realism of Brits, and won’t be able to effectively control costs by denying cost-ineffective treatments.
  - FireBeyond 7y ago
    Well, that article talks about blaming Big Pharma for the costs that make it expensive, not the National Health Service. With the big pool comes big leverage. The NHS effectively said "We're not paying that much", and the pharmaceutical companies decided they'd rather be paid something. Because if someone is not getting treatment, then they're not getting those drugs. Medicare in the US does this. "This is what we are paying for this drug". The issue isn't so much this. It's that drug industry lobbies in the US will have far more sway over the politics of this than they would in the UK (or Canada, or Australia, or...). I definitely don't claim to be an expert on these things. But I have lived in the UK with the NHS, in Australia with its medical system, and now in the US. In addition to that, I've worked as a healthcare provider, and for a Health Benefits Management software company, so I'd at least like to think I have something of a varied perspective.
    - rayiner 7y ago
      The very first part of the article explains how the NHS denied coverage for certain breast cancer drugs because it was too expensive. My concern is that the Americans won’t be willing to do that. Here, you see all these articles talking about how terrible it is that families went bankrupt going out of pocket after they hit a $1 million cap. The UK wouldn’t have paid for that treatment in the first place.
      - roywiggins 7y ago
        You have an admirable faith the American insurance companies don't do exactly the same thing, with much less oversight. https://www.nytimes.com/2019/02/27/obituaries/carrie-ann-lucas-dead.html https://www.nytimes.com/2019/02/27/obituaries/carrie-ann-luc... > Her family said an antibiotic Lucas needed to treat her symptoms cost about $2,000 and her insurance company denied coverage of the medicine, leading her to take a less-effective drug. Lucas, who was allergic to multiple drugs and antibiotics, had a reaction to that medication, Lee Lucas said.
        selimthegrim 7y ago

deleted 7y ago

[deleted]

pdonis 7y ago

> Healthcare is best managed as a risk pool. No, health insurance is best managed as a risk pool, which, as you say, should obviously be everyone. But much of health care is not health insurance because it doesn't deal with insurable risks. Your need to get an annual physical isn't an insurable risk. Neither is a one-time appointment with a doctor to see if your headache and runny nose is just a cold or an infection that requires antibiotics. The first isn't insurable because it's a predictable recurring cost; the second isn't because it's a routine service that shouldn't be so expensive that you can't pay it out of pocket. Health insurance should be focused on the things that are insurable risks: emergency care, hospitalization, etc. Things that aren't insurable risks, like the above, should be handled differently. But our health care system insists on treating these very different things the same, which of course is going to lead to huge inefficiencies and high costs.

ericpauley 7y ago
While this may make sense from the perspective of why people get insurance (to mitigate a catastrophic loss), it doesn't consider the insurer's incentives. No insurance company will want to underwrite a plan that doesn't bundle routine services, since those clearly reduce risk of complications down the road. A yearly checkup is cheap compared to missing a disease and letting it get worse.
- pdonis 7y ago
  > No insurance company will want to underwrite a plan that doesn't bundle routine services, since those clearly reduce risk of complications down the road But current plans don't require you to get routine services like an annual physical; they just cover them if you get them. That doesn't make sense if the insurer's incentives that you describe are driving the plan. Also, these incentives don't seem to be operating in other insurance markets. For example, auto insurance doesn't cover routine maintenance like oil changes or tire rotation.
  - epicureanideal 7y ago
    Maybe we should have two separate kinds of health insurance? One for true emergencies (like car accidents), and rare life threatening diseases (like cancer before 60). Another for routine things, but as others have said, routine things shouldn't be so expensive. I like the idea of structuring it like a term life insurance policy. If you die, you get money, and in some policies you even get some percentage before you die to have fun. So, if you get cancer or whatever, perhaps you'd have a pool of funds available to you to deal with the disease, and you can use that money how you want, and perhaps even keep the remainder (or a portion of it) to incentivize keeping cost down. Also, it would make sense for the pool of funds available to someone to be based on remaining years. If you get cancer when you 20 it makes sense to spend a million dollars trying to cure that. If you're 90, maybe it makes sense to treat it but not as aggressively or in as costly of ways. From the perspective of building a society that you would be willing to be in, assuming you were randomly born into that society without knowing to what parents, I still think many people would agree they'd rather spend heavily on younger people than older.

manfredo 7y ago

> Healthcare is best managed as a risk pool. The bigger the pool, the cheaper to be in it. The biggest risk pool is everyone. Therefore, we should put everyone in a single pool. No, whether or not expanding the pool raises costs depends on the cost of the added population. If 80% of the population is insured, and they consume an average of $1,000 in healthcare costs each year and the uninsured population consumes $10,000/yr then expanding the risk pool to the entire population will increase the cost of insurance. We saw this happen firsthand when we mandated that insurers take on all patients at the same cost regardless of prior conditions. The population that was added to the risk pool was more expensive than average, thus driving up the cost charged per person. Universal healthcare isn't a magic wand that makes healthcare costs go down, these plans are affordable for the average person because they are paid for by taxes which are levied at different rates depending on income. I many of these countries if you charged the cost of healthcare per person on people's post-tax income (and adding back in the tax paid for healthcare) they would be paying a greater portion of their paycheck for healthcare than most Americans. The affordability isn't solved by dumping everyone into one risk pool, it's solved by changing the way healthcare is paid for. Furthermore, most universal healthcare implementations don't put everyone in the same risk pool they tax and give citizens funds to spend on healthcare but the risk pools themselves are managed by insurance companies.

thatoneuser 7y ago

Why should we, the conscientious readers, trust your claim that you know what's best? Cuz it sounds like something that sounds good but which has no verifiable backing.

lordlimecat 7y ago

Healthcare in the states is asinine, no doubt. But when I see articles like this I have to ask, "why aren't these people making 75-100k using HSAs and FSAs"? They would eliminate many of these scenarios that people are seeing. There's the elephant in the room that many people are absolutely terrible with money, buying entertainment goods and completely skipping on savings, HSAs, etc that could prevent these media sob stories.