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> The "legitimacy" lies in the fact that that is what was politically possible to accomplish. Regulatory capture[0] narrowed the possible to only solutions inv

> The "legitimacy" lies in the fact that that is what was politically possible to accomplish. Regulatory capture[0] narrowed the possible to only solutions involving for-profit health insurance corporations. If you don't find a form of corruption to be of interest here, I'd be especially interested to know why. [0] https://en.wikipedia.org/wiki/Regulatory_capture https://en.wikipedia.org/wiki/Regulatory_capture

lotsofpulp 5y ago
I can see it being possible to have had some effect, but I do not see having been a major force. As far as I remember, Republicans did not want to expand access to healthcare at all if you did not already have it due to being very poor or old. Many Democrats wanted to expand taxpayer funded healthcare, but they did not have the numbers to get it passed. Hence a compromise had to be reached. Getting taxpayer funded healthcare administered by the federal government simply was not an option, and I have not seen evidence that it was because the health insurance business was lobbying every Republican. What I find more likely is that the more complex you make a system, the more you can engage in price discrimination via price obfuscation. A straight taxpayer funded healthcare option would have immediately impacted the bottom line, since government expenditures visibly go up, and would not allow a way to discriminate to those who receive the healthcare. The compromise, however, allows for all sorts of games to be played. Such as allocating more and better healthcare to older people in comparison to poorer people. This is accomplished simply by having different reimbursement polices in Medicare (old people, strong voting power) and Medicaid (poor people, weak voting power). Medicaid is also further broken down into being administer 50 different ways by 50 different states. Then you have employer self insured plans doing things the way they like, and employer subsidize plans doing things the way they like, and church plans that do not even provide healthcare. Basically, a way to expand healthcare in a way that still disproportionally allocates healthcare to richer and/or more politically influential people, but helping the others a little bit. At least we got the metal levels and healthcare.gov out of ACA so there is some ability to compare insurance products. And at the end of the day, even if you took away the cut that MCOs take for administering all this healthcare, it would mostly save around 5% to 10% (the profit margin plus savings from redundancies). MCOs currently pay out 75% to 80% of all premiums, and profit 5% or less, which leaves 15% to 20%, but the government would have to duplicate many of the functions of the MCO. https://www.kff.org/private-insurance/issue-brief/data-note-2021-medical-loss-ratio-rebates/ https://www.kff.org/private-insurance/issue-brief/data-note-... Even in a taxpayer funded scenario, I would bet the doctor is going to have to get approval from the system to provide a treatment above a certain cost.
- matheusmoreira 5y ago
  > Even in a taxpayer funded scenario, I would bet the doctor is going to have to get approval from the system to provide a treatment above a certain cost. That happens due to scarce resources. Most often in developing countries. Where I live, there are places doctors work at that barely have water for them to wash their hands. Ordering an MRI is a big deal. I refuse to believe this would ever be a problem for the US.
  - lotsofpulp 5y ago
    I do not know what to tell you other than "the US" expects many of its school teachers to procure classroom supplies themselves and it is a debate on whether or not to provide nutritious meals to kids in school without payment. We have a special visa for doctors willing to live in undesirable areas of the US for many years. There is even a website for it: https://data.hrsa.gov/tools/shortage-area https://data.hrsa.gov/tools/shortage-area https://www.hhs.gov/guidance/document/hpsa-and-muap-shortage-designation-types https://www.hhs.gov/guidance/document/hpsa-and-muap-shortage... And now to meet demand for doctors without having to pay for more doctors, most states have allowed a Nurse Practitioner or Physician Assistant to basically practice as a doctor where a doctor just oversees their clerical work. So if you have lesser insurance coverage or live in an area with insufficient doctors, then you may see an NP or PA who is far less qualified than a doctor.

lotsofpulp 5y ago

I can see it being possible to have had some effect, but I do not see having been a major force. As far as I remember, Republicans did not want to expand access to healthcare at all if you did not already have it due to being very poor or old. Many Democrats wanted to expand taxpayer funded healthcare, but they did not have the numbers to get it passed. Hence a compromise had to be reached. Getting taxpayer funded healthcare administered by the federal government simply was not an option, and I have not seen evidence that it was because the health insurance business was lobbying every Republican. What I find more likely is that the more complex you make a system, the more you can engage in price discrimination via price obfuscation. A straight taxpayer funded healthcare option would have immediately impacted the bottom line, since government expenditures visibly go up, and would not allow a way to discriminate to those who receive the healthcare. The compromise, however, allows for all sorts of games to be played. Such as allocating more and better healthcare to older people in comparison to poorer people. This is accomplished simply by having different reimbursement polices in Medicare (old people, strong voting power) and Medicaid (poor people, weak voting power). Medicaid is also further broken down into being administer 50 different ways by 50 different states. Then you have employer self insured plans doing things the way they like, and employer subsidize plans doing things the way they like, and church plans that do not even provide healthcare. Basically, a way to expand healthcare in a way that still disproportionally allocates healthcare to richer and/or more politically influential people, but helping the others a little bit. At least we got the metal levels and healthcare.gov out of ACA so there is some ability to compare insurance products. And at the end of the day, even if you took away the cut that MCOs take for administering all this healthcare, it would mostly save around 5% to 10% (the profit margin plus savings from redundancies). MCOs currently pay out 75% to 80% of all premiums, and profit 5% or less, which leaves 15% to 20%, but the government would have to duplicate many of the functions of the MCO. https://www.kff.org/private-insurance/issue-brief/data-note-2021-medical-loss-ratio-rebates/ https://www.kff.org/private-insurance/issue-brief/data-note-... Even in a taxpayer funded scenario, I would bet the doctor is going to have to get approval from the system to provide a treatment above a certain cost.

matheusmoreira 5y ago
> Even in a taxpayer funded scenario, I would bet the doctor is going to have to get approval from the system to provide a treatment above a certain cost. That happens due to scarce resources. Most often in developing countries. Where I live, there are places doctors work at that barely have water for them to wash their hands. Ordering an MRI is a big deal. I refuse to believe this would ever be a problem for the US.
- lotsofpulp 5y ago
  I do not know what to tell you other than "the US" expects many of its school teachers to procure classroom supplies themselves and it is a debate on whether or not to provide nutritious meals to kids in school without payment. We have a special visa for doctors willing to live in undesirable areas of the US for many years. There is even a website for it: https://data.hrsa.gov/tools/shortage-area https://data.hrsa.gov/tools/shortage-area https://www.hhs.gov/guidance/document/hpsa-and-muap-shortage-designation-types https://www.hhs.gov/guidance/document/hpsa-and-muap-shortage... And now to meet demand for doctors without having to pay for more doctors, most states have allowed a Nurse Practitioner or Physician Assistant to basically practice as a doctor where a doctor just oversees their clerical work. So if you have lesser insurance coverage or live in an area with insufficient doctors, then you may see an NP or PA who is far less qualified than a doctor.