7 ms·

Medicare Advantage is incredibly predatory and a misalignment of incentives. It pushes what should be a socialized program to the free market, which abuses it a

Medicare Advantage is incredibly predatory and a misalignment of incentives. It pushes what should be a socialized program to the free market, which abuses it and rejects care in order to turn a profit. It's very funny people were worried about ACA "Death Panels". The insurers offering Medicare advantage basically have doctors on their payroll acting exactly as people feared, except it's the free market so somehow that's okay?

Racing0461 3y ago
It's the trolly problem.
EvanAnderson 3y ago
I've observed that, too. "Death panels" conducted in public by parties appointed by accountable representatives are somehow repugnant, but having decisions made by completely unaccountable and inscrutable bodies is somehow okay. These decisions have to be made, why would we not want them made under some amount of public scrutiny?
- buildbot 3y ago
  Exactly. The sad reality is in any (mostly) closed system, say, the USA or even earth, there are resource limits and you might be able to do more good by treating 4 patients with more simple cancer's vs. 1 patient with a very complex cancer that requires 10 doctors, 20 scientists, and endless support staff working over months to create a personal gene therapy for you. It's difficult and sad, but as a sibling comment said, it's literally the Trolley problem. Until we live in a utopia with nearly limitless resources, then the problem still applies, in both the public and private sector. I'd rather have it be public too.
  - TehCorwiz 3y ago
    You’re assuming that the efforts don’t feed back into knowledge and treatment for other people when in reality it does. But even outside that extreme example people are regularly denied treatment for existing easily treated ailments.
  - fragmede 3y ago
    That assumes the 10 doctors and 20 scientists and support staff are fungible resources. Which they are not. Those 10 doctors have 10 different specialties and those scientists aren't going to suddenly become nurses that can administer the simple patient's therapies. Advances made in creating customized gene therapies will be used to help others, later.
    - xkekjrktllss 3y ago
      You're making an argument for a more organized society, not a less organized society. In your example, the solution is not letting 9 more people die but rather having a greater number of generalized doctors, in place of some specialized doctors if need be.
      - fragmede 3y ago
        my point is more that the less organized society that we have which lets people choose their own destiny leads to one where we don't have the generalists to save the 9, so it's less of a trolley problem because of the difference in urgency.
        xkekjrktllss 3y ago
        You are failing to make your point. What urgency are you talking about?
        fragmede 3y ago
        Trolley problem is to choice to flip a switch. If the switch to be flipped results in their deaths in 5 minutes is different than a decision that takes 10 years of advanced schooling to see the results.
        xkekjrktllss 3y ago
        This is irrelevant. We either plan and fix the problem or we don't plan and don't fix the problem. That's it. There are no terms in which any proposal of yours even improves the results, so you have no point.
  - varelse 3y ago
    [dead]
  - konschubert 3y ago
    That’s why we need economic growth
    - konschubert 3y ago
      To the people downvoting: Would you elaborate why you think I’m wrong?
- dragonwriter 3y ago
  > but having decisions made by completely unaccountable and inscrutable bodies is somehow okay. They are accountable—directly and exclusively to capital—which is both why they are okay to the people funding the political propaganda in question and why the alternative (where that is not true, since there is, at least indirect, democratic accountability) is not. Capitalism and democracy are different, and fundamentally conflicting, systems of organizing power. This is often overlooked because capitalism is described as “economic” and democracy as “political”, but those are different ways of describing systems of organizing power over others which is fungible between domains.
- phpisthebest 3y ago
  >>conducted in public by parties appointed by accountable representatives are somehow repugnant, Well this where you find the problem, to me and many many others choosing a medical / insurance providers from an array of medical / insurance providers seems to provide MUCH MUCH more accountability then "parties appointed by accountable representatives " who are not really accountable at all, and whom elections are based on any number of issues very rarely would be the status of medical dealth panels, for the US currently would the "hot button" topics of the day (and for the last several decades) immigration, abortion and gun control This mythical idea that elections are how we hold the unelected bureaucracy in check has many many many examples of being completely and utterly false, unelected bureaucracy has ZERO fear of the election cycle most of the time. Meet the new boss, sames as the old boss, and almost none of them every leave. Of all the industries government bureaucracy has some of the longest tenured employees next only to education where once a person joins an agency they never leave until death or retirement. The Rare Exception is the regulatory capture of ruling making boards and committee's where there is a revolving corrupt door between the public and private sectors.
WalterBright 3y ago
It's not a free market. The government funds it.
jack_h 3y ago
I really don't know much about Medicare so I decided to visit the wikipedia page on this. Here is how it describes Medicare Advantage: > Medicare Advantage (Medicare Part C, MA) is a capitated program for providing Medicare benefits in the United States. Under Part C, Medicare pays a sponsor a fixed payment. The sponsor then pays for the health care expenses of enrollees. Sponsors are allowed to vary the benefits from those provided by Medicare's Parts A and B as long as they provide the actuarial equivalent of those programs. > Plans must be approved by the Centers for Medicare and Medicaid Services (CMS). If a MA plan changes some benefits, the savings must be passed along to consumers by lowering co-payments for doctor visits (or any other plus or minus aggregation approved by CMS).[2] Coverage must include inpatient hospital (Part A) and outpatient (Part B) services. > Original Medicare and Medicare Advantage pay healthcare providers differently. Original Medicare typically reimburses healthcare providers with a fee for each service.[5] This fee is often calculated with a standard formula (for example, the prospective payment system for hospital services). Providers either accept Medicare's reimbursement rates or opt out of the program.[5] Public Medicare Advantage plans negotiate payment rates and form networks with healthcare providers, similar to private health insurance plans that almost all Americans not of Medicare age use. Is it that last part that turns this into the "free market"? My lay reading of just the wikipedia page doesn't give me the impression that any part of this is subject to free market forces. What am I missing?
- borski 3y ago
  Yes, it’s the last part. Medicare has set prices it will pay [0], period, and Medicare is not prone to denying procedures that a physician thinks is necessary. This is a public socialized good. MA plans negotiate with providers, similar to a regular commercial insurance company, for different “deals.” As you may be aware from commercial insurance, that typically means higher rates, since everyone along the line has to get paid across the providers and the insurance companies. Much higher profit motive than a socialized good. On top of that, MA plans have an incentive to deny coverage wherever possible, because as a for-profit entity they want to make as much money as possible, not get old people healthier. Young people have trouble fighting insurers on denials. I know this firsthand. But it’s doable, because we tend to have more energy and less cognitive impairment; I’m generalizing here, but dementia is a thing that happens to a lot of people in old age, for example. For older people, fighting insurance companies is just about impossible. Often, this falls on their younger family members to help (ask me how I know, lol), but that implies their family or friends are willing to help. Not everyone has that. And it shouldn’t be that way. [0] There is a thing called Excess Charges that providers can charge, if they don’t accept the Medicare fee table, but still accept Medicare generally. They have to tell you before the service, or you are not responsible. It is also capped at 15% of the service, and is illegal in some states entirely, and capped lower in others. Some Medigap plans also cover excess charges, but they are on the more expensive end.
scarface_74 3y ago
So how do you fully socialize a program and balance supply and demand? Don’t get me wrong, as someone who saw first hand the shit show of the pre ACA, something had to be done. I was laid off right before the ACA took affect and couldn’t get insurance at any price because of a non life threatening, no treatment needed then or in the future preexisting condition. I was healthy as a horse and had just run my first two half marathons. COBRA wasn’t an option because the company I was laid off from went out of business. I had a well paying contract job and I could have afforded to pay out of pocket premiums. I ended up marrying my now wife six months earlier than we had plan to get on her insurance (her idea). But the challenge is end of life care and you will always have to make cost/benefit trade offs.
pdonis 3y ago
I'm no fan of Medicare Advantage (or indeed of Medicare in general), but it is not a "free market" program. It has the same problem all socialized health care programs have: the people who are actually getting the care, patients, have no idea what it costs, so they can't judge whether the care they are getting is worth the cost. A free market program would be one in which the patients paid the costs directly and could shop around for the best deal, just like in the rest of the free market. If you want to help people who might not have the money to pay those costs directly, the obvious thing to do would be to subsidize them, the way we subsidize food purchases now for the poor with food stamps. Food stamps just give people a monthly sum they can spend on food; they don't go and negotiate prices with all the grocery stores and then argue after the fact about whether a particular food purchase was covered. It is true that in some situations, like emergencies or accidents, patients can't shop around. That kind of situation is indeed what insurance is for. But programs like Medicare, and indeed socialized health care in general, go way beyond insurance. Insurance is for high cost unforeseen events. Most health care is not high cost unforeseen events; it's foreseen events like physicals, shots, checkups and prescriptions for chronic conditions, etc., or low cost unforeseen events like getting an infection and needing treatment. If all of those things were provided in a free market, health care providers would be much more efficient, and it would be much easier to negotiate reasonable terms for insurance for the truly high cost unforeseen events that insurance is for. Medicare Advantage (and Medicare and socialized health care in general) is of course nothing at all like that.
- tcbawo 3y ago
  It’s very difficult to shop around when there are few options to shop around at. Also impeding the free market is a low supply of medical expertise. There has been a lot of consolidation in provider networks and systems. Many doctors and nurses have been leaving the profession due to stress, overwork, liability insurance, etc.
  - pdonis 3y ago
    All of the issues you describe, which are all valid issues, are consequences of the lack of a free market. Medical expertise is not provided in a free market; doctors have to be licensed by the government. Consolidation of companies is due to the fact that there are economies of scale to be had when your company has to specialize in government contracting and lobbying (the consolidation of defense contractors over decades has happened for similar reasons). Doctors and nurses are stressed and overworked because their supply is limited (due to licensing, as above) and because limited time and tons of bureaucracy due to all the third party players involved (players that wouldn't even have a say in the process at all in a free market) gets in the way of caring for patients.

Racing0461 3y ago

It's the trolly problem.

EvanAnderson 3y ago

I've observed that, too. "Death panels" conducted in public by parties appointed by accountable representatives are somehow repugnant, but having decisions made by completely unaccountable and inscrutable bodies is somehow okay. These decisions have to be made, why would we not want them made under some amount of public scrutiny?

buildbot 3y ago
Exactly. The sad reality is in any (mostly) closed system, say, the USA or even earth, there are resource limits and you might be able to do more good by treating 4 patients with more simple cancer's vs. 1 patient with a very complex cancer that requires 10 doctors, 20 scientists, and endless support staff working over months to create a personal gene therapy for you. It's difficult and sad, but as a sibling comment said, it's literally the Trolley problem. Until we live in a utopia with nearly limitless resources, then the problem still applies, in both the public and private sector. I'd rather have it be public too.
- TehCorwiz 3y ago
  You’re assuming that the efforts don’t feed back into knowledge and treatment for other people when in reality it does. But even outside that extreme example people are regularly denied treatment for existing easily treated ailments.
- fragmede 3y ago
  That assumes the 10 doctors and 20 scientists and support staff are fungible resources. Which they are not. Those 10 doctors have 10 different specialties and those scientists aren't going to suddenly become nurses that can administer the simple patient's therapies. Advances made in creating customized gene therapies will be used to help others, later.
  - xkekjrktllss 3y ago
    You're making an argument for a more organized society, not a less organized society. In your example, the solution is not letting 9 more people die but rather having a greater number of generalized doctors, in place of some specialized doctors if need be.
    - fragmede 3y ago
      my point is more that the less organized society that we have which lets people choose their own destiny leads to one where we don't have the generalists to save the 9, so it's less of a trolley problem because of the difference in urgency.
      - xkekjrktllss 3y ago
        You are failing to make your point. What urgency are you talking about?
        fragmede 3y ago
        Trolley problem is to choice to flip a switch. If the switch to be flipped results in their deaths in 5 minutes is different than a decision that takes 10 years of advanced schooling to see the results.
        xkekjrktllss 3y ago
        This is irrelevant. We either plan and fix the problem or we don't plan and don't fix the problem. That's it. There are no terms in which any proposal of yours even improves the results, so you have no point.
- varelse 3y ago
  [dead]
- konschubert 3y ago
  That’s why we need economic growth
  - konschubert 3y ago
    To the people downvoting: Would you elaborate why you think I’m wrong?
dragonwriter 3y ago
> but having decisions made by completely unaccountable and inscrutable bodies is somehow okay. They are accountable—directly and exclusively to capital—which is both why they are okay to the people funding the political propaganda in question and why the alternative (where that is not true, since there is, at least indirect, democratic accountability) is not. Capitalism and democracy are different, and fundamentally conflicting, systems of organizing power. This is often overlooked because capitalism is described as “economic” and democracy as “political”, but those are different ways of describing systems of organizing power over others which is fungible between domains.
phpisthebest 3y ago
>>conducted in public by parties appointed by accountable representatives are somehow repugnant, Well this where you find the problem, to me and many many others choosing a medical / insurance providers from an array of medical / insurance providers seems to provide MUCH MUCH more accountability then "parties appointed by accountable representatives " who are not really accountable at all, and whom elections are based on any number of issues very rarely would be the status of medical dealth panels, for the US currently would the "hot button" topics of the day (and for the last several decades) immigration, abortion and gun control This mythical idea that elections are how we hold the unelected bureaucracy in check has many many many examples of being completely and utterly false, unelected bureaucracy has ZERO fear of the election cycle most of the time. Meet the new boss, sames as the old boss, and almost none of them every leave. Of all the industries government bureaucracy has some of the longest tenured employees next only to education where once a person joins an agency they never leave until death or retirement. The Rare Exception is the regulatory capture of ruling making boards and committee's where there is a revolving corrupt door between the public and private sectors.

WalterBright 3y ago

It's not a free market. The government funds it.

jack_h 3y ago

I really don't know much about Medicare so I decided to visit the wikipedia page on this. Here is how it describes Medicare Advantage: > Medicare Advantage (Medicare Part C, MA) is a capitated program for providing Medicare benefits in the United States. Under Part C, Medicare pays a sponsor a fixed payment. The sponsor then pays for the health care expenses of enrollees. Sponsors are allowed to vary the benefits from those provided by Medicare's Parts A and B as long as they provide the actuarial equivalent of those programs. > Plans must be approved by the Centers for Medicare and Medicaid Services (CMS). If a MA plan changes some benefits, the savings must be passed along to consumers by lowering co-payments for doctor visits (or any other plus or minus aggregation approved by CMS).[2] Coverage must include inpatient hospital (Part A) and outpatient (Part B) services. > Original Medicare and Medicare Advantage pay healthcare providers differently. Original Medicare typically reimburses healthcare providers with a fee for each service.[5] This fee is often calculated with a standard formula (for example, the prospective payment system for hospital services). Providers either accept Medicare's reimbursement rates or opt out of the program.[5] Public Medicare Advantage plans negotiate payment rates and form networks with healthcare providers, similar to private health insurance plans that almost all Americans not of Medicare age use. Is it that last part that turns this into the "free market"? My lay reading of just the wikipedia page doesn't give me the impression that any part of this is subject to free market forces. What am I missing?

borski 3y ago
Yes, it’s the last part. Medicare has set prices it will pay [0], period, and Medicare is not prone to denying procedures that a physician thinks is necessary. This is a public socialized good. MA plans negotiate with providers, similar to a regular commercial insurance company, for different “deals.” As you may be aware from commercial insurance, that typically means higher rates, since everyone along the line has to get paid across the providers and the insurance companies. Much higher profit motive than a socialized good. On top of that, MA plans have an incentive to deny coverage wherever possible, because as a for-profit entity they want to make as much money as possible, not get old people healthier. Young people have trouble fighting insurers on denials. I know this firsthand. But it’s doable, because we tend to have more energy and less cognitive impairment; I’m generalizing here, but dementia is a thing that happens to a lot of people in old age, for example. For older people, fighting insurance companies is just about impossible. Often, this falls on their younger family members to help (ask me how I know, lol), but that implies their family or friends are willing to help. Not everyone has that. And it shouldn’t be that way. [0] There is a thing called Excess Charges that providers can charge, if they don’t accept the Medicare fee table, but still accept Medicare generally. They have to tell you before the service, or you are not responsible. It is also capped at 15% of the service, and is illegal in some states entirely, and capped lower in others. Some Medigap plans also cover excess charges, but they are on the more expensive end.

scarface_74 3y ago

So how do you fully socialize a program and balance supply and demand? Don’t get me wrong, as someone who saw first hand the shit show of the pre ACA, something had to be done. I was laid off right before the ACA took affect and couldn’t get insurance at any price because of a non life threatening, no treatment needed then or in the future preexisting condition. I was healthy as a horse and had just run my first two half marathons. COBRA wasn’t an option because the company I was laid off from went out of business. I had a well paying contract job and I could have afforded to pay out of pocket premiums. I ended up marrying my now wife six months earlier than we had plan to get on her insurance (her idea). But the challenge is end of life care and you will always have to make cost/benefit trade offs.

pdonis 3y ago

I'm no fan of Medicare Advantage (or indeed of Medicare in general), but it is not a "free market" program. It has the same problem all socialized health care programs have: the people who are actually getting the care, patients, have no idea what it costs, so they can't judge whether the care they are getting is worth the cost. A free market program would be one in which the patients paid the costs directly and could shop around for the best deal, just like in the rest of the free market. If you want to help people who might not have the money to pay those costs directly, the obvious thing to do would be to subsidize them, the way we subsidize food purchases now for the poor with food stamps. Food stamps just give people a monthly sum they can spend on food; they don't go and negotiate prices with all the grocery stores and then argue after the fact about whether a particular food purchase was covered. It is true that in some situations, like emergencies or accidents, patients can't shop around. That kind of situation is indeed what insurance is for. But programs like Medicare, and indeed socialized health care in general, go way beyond insurance. Insurance is for high cost unforeseen events. Most health care is not high cost unforeseen events; it's foreseen events like physicals, shots, checkups and prescriptions for chronic conditions, etc., or low cost unforeseen events like getting an infection and needing treatment. If all of those things were provided in a free market, health care providers would be much more efficient, and it would be much easier to negotiate reasonable terms for insurance for the truly high cost unforeseen events that insurance is for. Medicare Advantage (and Medicare and socialized health care in general) is of course nothing at all like that.

tcbawo 3y ago
It’s very difficult to shop around when there are few options to shop around at. Also impeding the free market is a low supply of medical expertise. There has been a lot of consolidation in provider networks and systems. Many doctors and nurses have been leaving the profession due to stress, overwork, liability insurance, etc.
- pdonis 3y ago
  All of the issues you describe, which are all valid issues, are consequences of the lack of a free market. Medical expertise is not provided in a free market; doctors have to be licensed by the government. Consolidation of companies is due to the fact that there are economies of scale to be had when your company has to specialize in government contracting and lobbying (the consolidation of defense contractors over decades has happened for similar reasons). Doctors and nurses are stressed and overworked because their supply is limited (due to licensing, as above) and because limited time and tons of bureaucracy due to all the third party players involved (players that wouldn't even have a say in the process at all in a free market) gets in the way of caring for patients.