3 ms·

The Monty Hall problem has nothing to do with his statistics, which in any case are completely dependent on his unsupported assertions, cf.: "If, as I suspect,

The Monty Hall problem has nothing to do with his statistics, which in any case are completely dependent on his unsupported assertions, cf.: "If, as I suspect, rescission is targeted toward the truly bankrupting cases – the top 1%..." "But let’s not forget that the very nature of the forms is designed to create inaccuracies" Not to mention: "I tend to think of traditional banking and traditional insurance as mirror images: when you take out a mortgage, you get a lump sum and make a series of payments; when you get life insurance, you make a series of payments and get a lump sum." Which pretty much sums up the problem with the current health care debate -- almost nobody involved knows the difference between insurance and care. There's no reason middlish class people need to have things like physicians' visits and normal prescription drugs filtered through an insurance company or the government, they're completely affordable and expectable on their own. You insure unexpected, unaffordable events, like crashing your car, not oil changes.

kgrin 17y ago
That's true, though if you're on the hook for a person's catastrophic care, you may very well want to give them economic incentives (i.e. cheap/free doctor's checkups) to invest in preventative care. Now, this doesn't mean that we ought to necessarily have a big, bad program (government or private) control everything. But it does mean that the "insurance is for catastrophes, everything else should be out-of-pocket" model isn't necessarily as simple and wonderful as it sounds.
- jdminhbg 17y ago
  That's true if the assumptions behind it are true -- that cheap/free doctor's checkups result in lower catastrophic care costs. I'm not aware of any study that shows that they are.
  - kgrin 17y ago
    I don't have the studies in front of me, but it generally depends. In the case of diabetes, for instance, a lifetime of diet monitoring and counseling by a doctor or nurse is still way cheaper than insulin or amputation.
    - jdminhbg 17y ago
      The diabetes example is not one I had thought of, I'll look into it. What bothers me is that I see a lot of knee-jerk "we'll just make it up on preventative care" in the debate, without any way of proving how the costs add up. Without having looked into it deeper, my question about diabetes would be whether free/cheap checkups and counseling affect the number of people who correctly handle their problem.
      - kgrin 17y ago
        There's a pretty clear medical consensus (based on tons of data) that diet and exercise affects the development or progression of diabetes (well, type II). There's also a wide consensus that professional counseling and monitoring helps (though I believe it's harder to get really "clean" studies to support this, since you'd need a control group of people who you monitor closely enough to get good comparison data without actually talking to them about what's going on). The follow-up question, of course, is whether (or how much) the cost of checkups/counseling affects whether/how much people seek it out, or whether that behavior is more idiosyncratic (i.e. "some people just don't care about their health, so even if checkups were free they wouldn't bother"). To be fair, I haven't seen any study that conclusively proves the issue (which of course doesn't imply that one isn't out there). However, if we're really going to make the claim that economic incentives don't matter, then we really need to question a lot of other assumptions as well. I'm pretty comfortable saying that at least on some level, to some degree, economic incentives have some impact on people's behavior in seeking care. In terms of "we'll just make it up on preventative care", I agree, that's not a panacea. At the same time, a lot of the money that's slated to be spent on covering the uninsured is still spent today, just in really stupidly inefficient ways. For instance, because you generally can't be denied emergency room care, people without insurance often end up using ERs as primary care. Because ERs are primarily meant to handle, well, emergencies, the standard of care is generally more expensive than a clinic or "regular doctor" (this means things like faster and more expensive tests, drugs, and so forth). Many of those people simply can't pay, but the hospital treated them anyway (which, just to be clear, is a GOOD thing - it would be a pretty horrid society where we let people bleed to death or what have you). Many hospitals would have a hard time staying open if this went on indefinitely, so the government reimburses them for this uninsured care. So, at the end of the day "we the taxpayers" still pay for a good deal of uninsured care... we just do it via an indirect subsidy to hospitals for expensive ER care, rather than paying directly for (much cheaper) clinic care, or something along those lines. As with most things, the less directly we're tackling the problem, the more inefficiency there is in the system. It would be foolish to claim that all the costs of a big health care/health insurance overhaul would be paid for by money already in the system - clearly, that depends a great deal on the details. But at the same time, it's important to remember that some of the money can come from within the system: at a minimum, if we reduce the number of uninsured people, we can reduce payments to hospitals for uninsured care. It's not a zero-sum game - electronic medical records and that sort of stuff aside, there's a lot of honest-to-goodness inefficiency and perverse incentives in the system, and that's what (a good) reform ought to tackle. Edit: just to be clear, reimbursements for uninsured care take many forms, and there's another, more obvious one: higher prices for everybody else. The salient point is that much of this care is being provided anyway, so why not do it more efficiently?
- Empact 17y ago
  It's actually quite common for High-Deductible plans to include payment for standard preventative care (e.g. annual physical). After all the costs covered are predictable and well-contained anyway (typically a few hundred a year). Beyond that, the emerging "direct Primary Care" model (e.g. http://qliance.com/ http://qliance.com/) is another way to remove the financial disincentive to use preventative care. With them you get unlimited around-the-clock primary care for $50+/month, so there's no additional cost to come in for a checkup. And the barriers to interacting with them are even lower than an insurance-bound doctor, as they embrace modern forms of communication so you can e-mail them about problems which otherwise would not have risen to the level of motivating an appointment. Note that in this case, subscribers would then favor insurance which does not cover preventative care, or else they'd be paying for it twice, so it's not necessarily beneficial that all people get this support from their insurance.
jhancock 17y ago
The essential problem is that the person paying the premium is not the insurance companies "customer". The health insurance company's customer is the shareholder, not the premium payer, that has to end. I have built software for health insurance companies. I can tell you for certain they only look at the details of a policy for rescission purposes for those policies that are costing them far more than the premium has been paying. And if you watch the congress video embedded in the blog post http://www.youtube.com/watch?v=2H9ufue_1uI&eurl=http%3A%2F%2Ftauntermedia%2Ecom%2F2009%2F07%2F28%2Funconscionable%2Dmath%2F&feature=player_embedded http://www.youtube.com/watch?v=2H9ufue_1uI&eurl=http%3A%..., it makes perfectly clear that the application part of a policy is very easy to find "flaws" with retroactively if the insurance company choses.
- weaksauce 17y ago
  That is so true. The insurance companies for health care should be non-profits with set salaries for all the employees. The reason that people buy health insurance is for exactly the reason that the insurance companies drop the insured; They cost more money than they spend.
  - kgrin 17y ago
    The latter point isn't entirely true - at its core, buying insurance isn't necessarily about using more than you put in over time, but rather mitigating risks (hedging). That's not necessarily how everyone treats the current system, or for that matter how it's set up, but there's certainly a tension between the "insurance" model and the "health savings account" model (and the current system sort of tries to do both). In terms of insurance companies being run as non-profits, let me ask two pointed (and I assure you, not-meant-to-be-trollish) questions: 1) If insurance companies should be non-profits with set salaries and so forth, why not just have the government do it at that point? 2) Two recently prominent examples of non-profits set up to further socially useful goals without actually being government agencies are Sallie Mae and Freddie Mac. Those didn't turn out so hot. How would you set up these non-profits to avoid the same sorts of problems? Actually, I should throw in a third: does anyone know of any examples (successful or not) of a non-profit insurance entity or cooperative?
yummyfajitas 17y ago
* There's no reason middlish class people need to have things like physicians' visits and normal prescription drugs filtered through an insurance company or the government, they're completely affordable and expectable on their own.* There is a good reason for this: tax avoidance. "Insurance" (against everything) is paid for with pre-tax dollars. Doctor visits are paid for with post-tax dollars (ignoring HSA's, etc). If car insurance got the same tax benefits, then car insurance which pays for gas would probably be available.

kgrin 17y ago

That's true, though if you're on the hook for a person's catastrophic care, you may very well want to give them economic incentives (i.e. cheap/free doctor's checkups) to invest in preventative care. Now, this doesn't mean that we ought to necessarily have a big, bad program (government or private) control everything. But it does mean that the "insurance is for catastrophes, everything else should be out-of-pocket" model isn't necessarily as simple and wonderful as it sounds.

jdminhbg 17y ago
That's true if the assumptions behind it are true -- that cheap/free doctor's checkups result in lower catastrophic care costs. I'm not aware of any study that shows that they are.
- kgrin 17y ago
  I don't have the studies in front of me, but it generally depends. In the case of diabetes, for instance, a lifetime of diet monitoring and counseling by a doctor or nurse is still way cheaper than insulin or amputation.
  - jdminhbg 17y ago
    The diabetes example is not one I had thought of, I'll look into it. What bothers me is that I see a lot of knee-jerk "we'll just make it up on preventative care" in the debate, without any way of proving how the costs add up. Without having looked into it deeper, my question about diabetes would be whether free/cheap checkups and counseling affect the number of people who correctly handle their problem.
    - kgrin 17y ago
      There's a pretty clear medical consensus (based on tons of data) that diet and exercise affects the development or progression of diabetes (well, type II). There's also a wide consensus that professional counseling and monitoring helps (though I believe it's harder to get really "clean" studies to support this, since you'd need a control group of people who you monitor closely enough to get good comparison data without actually talking to them about what's going on). The follow-up question, of course, is whether (or how much) the cost of checkups/counseling affects whether/how much people seek it out, or whether that behavior is more idiosyncratic (i.e. "some people just don't care about their health, so even if checkups were free they wouldn't bother"). To be fair, I haven't seen any study that conclusively proves the issue (which of course doesn't imply that one isn't out there). However, if we're really going to make the claim that economic incentives don't matter, then we really need to question a lot of other assumptions as well. I'm pretty comfortable saying that at least on some level, to some degree, economic incentives have some impact on people's behavior in seeking care. In terms of "we'll just make it up on preventative care", I agree, that's not a panacea. At the same time, a lot of the money that's slated to be spent on covering the uninsured is still spent today, just in really stupidly inefficient ways. For instance, because you generally can't be denied emergency room care, people without insurance often end up using ERs as primary care. Because ERs are primarily meant to handle, well, emergencies, the standard of care is generally more expensive than a clinic or "regular doctor" (this means things like faster and more expensive tests, drugs, and so forth). Many of those people simply can't pay, but the hospital treated them anyway (which, just to be clear, is a GOOD thing - it would be a pretty horrid society where we let people bleed to death or what have you). Many hospitals would have a hard time staying open if this went on indefinitely, so the government reimburses them for this uninsured care. So, at the end of the day "we the taxpayers" still pay for a good deal of uninsured care... we just do it via an indirect subsidy to hospitals for expensive ER care, rather than paying directly for (much cheaper) clinic care, or something along those lines. As with most things, the less directly we're tackling the problem, the more inefficiency there is in the system. It would be foolish to claim that all the costs of a big health care/health insurance overhaul would be paid for by money already in the system - clearly, that depends a great deal on the details. But at the same time, it's important to remember that some of the money can come from within the system: at a minimum, if we reduce the number of uninsured people, we can reduce payments to hospitals for uninsured care. It's not a zero-sum game - electronic medical records and that sort of stuff aside, there's a lot of honest-to-goodness inefficiency and perverse incentives in the system, and that's what (a good) reform ought to tackle. Edit: just to be clear, reimbursements for uninsured care take many forms, and there's another, more obvious one: higher prices for everybody else. The salient point is that much of this care is being provided anyway, so why not do it more efficiently?
Empact 17y ago
It's actually quite common for High-Deductible plans to include payment for standard preventative care (e.g. annual physical). After all the costs covered are predictable and well-contained anyway (typically a few hundred a year). Beyond that, the emerging "direct Primary Care" model (e.g. http://qliance.com/ http://qliance.com/) is another way to remove the financial disincentive to use preventative care. With them you get unlimited around-the-clock primary care for $50+/month, so there's no additional cost to come in for a checkup. And the barriers to interacting with them are even lower than an insurance-bound doctor, as they embrace modern forms of communication so you can e-mail them about problems which otherwise would not have risen to the level of motivating an appointment. Note that in this case, subscribers would then favor insurance which does not cover preventative care, or else they'd be paying for it twice, so it's not necessarily beneficial that all people get this support from their insurance.

jhancock 17y ago

The essential problem is that the person paying the premium is not the insurance companies "customer". The health insurance company's customer is the shareholder, not the premium payer, that has to end. I have built software for health insurance companies. I can tell you for certain they only look at the details of a policy for rescission purposes for those policies that are costing them far more than the premium has been paying. And if you watch the congress video embedded in the blog post http://www.youtube.com/watch?v=2H9ufue_1uI&eurl=http%3A%2F%2Ftauntermedia%2Ecom%2F2009%2F07%2F28%2Funconscionable%2Dmath%2F&feature=player_embedded http://www.youtube.com/watch?v=2H9ufue_1uI&eurl=http%3A%..., it makes perfectly clear that the application part of a policy is very easy to find "flaws" with retroactively if the insurance company choses.

weaksauce 17y ago
That is so true. The insurance companies for health care should be non-profits with set salaries for all the employees. The reason that people buy health insurance is for exactly the reason that the insurance companies drop the insured; They cost more money than they spend.
- kgrin 17y ago
  The latter point isn't entirely true - at its core, buying insurance isn't necessarily about using more than you put in over time, but rather mitigating risks (hedging). That's not necessarily how everyone treats the current system, or for that matter how it's set up, but there's certainly a tension between the "insurance" model and the "health savings account" model (and the current system sort of tries to do both). In terms of insurance companies being run as non-profits, let me ask two pointed (and I assure you, not-meant-to-be-trollish) questions: 1) If insurance companies should be non-profits with set salaries and so forth, why not just have the government do it at that point? 2) Two recently prominent examples of non-profits set up to further socially useful goals without actually being government agencies are Sallie Mae and Freddie Mac. Those didn't turn out so hot. How would you set up these non-profits to avoid the same sorts of problems? Actually, I should throw in a third: does anyone know of any examples (successful or not) of a non-profit insurance entity or cooperative?

yummyfajitas 17y ago

* There's no reason middlish class people need to have things like physicians' visits and normal prescription drugs filtered through an insurance company or the government, they're completely affordable and expectable on their own.* There is a good reason for this: tax avoidance. "Insurance" (against everything) is paid for with pre-tax dollars. Doctor visits are paid for with post-tax dollars (ignoring HSA's, etc). If car insurance got the same tax benefits, then car insurance which pays for gas would probably be available.