Affordable Care Act in US

[HB of CJ]

Interesting responses and thank you. Perhaps one of the many dangerous points of view is to imagine something that is simply not there. Again, the US Constitution means what it says and says what it means. Very simple language that still is understandable today. Particularly today. To imagine it meaning something else to suit ones liberal fancy is very hazardous. The Constitution is NOT a living document

 

The 10th Amendment also is very simply stated. Presented arguments here stating that "that ship has sailed" and related "living document" points of view, (thank you) fail. You can not imply something that is not there. Mandated National Health Care is very dangerous. Such mandates must come from the States respectfully OR ... from the individual desiring such health care. If you want something, YOU pay for it.

 

Respectfully.

[iNow]

...pegs the cost of private insurance vs. Medicaid at 18%. That's a difference, but it doesn't seem like a difference that completely rules out consideration of a fully privatized system.

Perhaps not, but you stipulate it's cheaper, which is my point. It also covers more, does a better job at controlling costs, and is more available to those who need it most.

 

There's no need to quibble whether it's worth paying more for private insurance or if Medicaid is 18% or 180% cheaper. It's cheaper and better. End program. Point made. You've acknowledged it. Moving forward...

 

There are a few problems I have with private insurance, my top three being that patients (or "shoppers") don't have access to enough information to make informed medical purchasing decisions, that healthcare fundamentally should not IMO be a profit motivated enterprise, and bargaining power is decreased when private insurers are used (wherein a national approach spreads the risk pool, minimizes individual expenditures, and offers the greatest negotiating leverage).

 

Healthcare profits in the US come on the backs of the sickest and weakest among us. This is a morality argument, but an important one. Families shouldn't be launched into bankruptcy from cancer or related ails, events they have no control over and which happen through no fault of their own. My neighbors baby shouldn't have to die due simply to its parents not being as fortunate as me. That's a values based position and I'm sure others will disagree, but it's my starting point.

 

Healthcare costs in the US are the top cause of personal bankruptcy. The numbers thankfully dropped when ACA passed, but they're still there and still far too high. Some may disagree, but I feel someone shouldn't have to lose their home or go without eating or work a 4th job just so they can have health coverage if anything happens. We readily spend billions on bombers but for some reason can't bring ourselves to use our fabulous wealth for the far reaching security and wellbeing of our fellow citizens.

 

No matter how you look at it, nationalized healthcare is cheaper, offers the highest ROI, and covers the most people without the accompanying moral and ethical issues private insurance carries. We waste less and get more. The math is clear and the only reason to stand opposed is ideological.

 

Distilled to the barest essence, private insurance is a profit driven business and consequently has one motivation... to make money and maximize profit. Taken to its logical end, their business model pushes them to charge the highest possible premiums (increase revenue) and payout the lowest possible amount on claims (reduce costs). This approach is fabulous in most markets, but is directly oppositional to what healthcare priorities should be... namely, the health and wellbeing of us and our families.

 

While small government minded folks understandably prefer private coverage models, fiscally conservative, genuinely compassionate, cost averse ones have no choice but to prefer single-payer... Medicare for all. This has the peripheral benefit of being the most moral, kind, and historically just approach to this issue, but that's just icing on top of the actuarial cake.

 

AFAIC, universal healthcare is NOT a radical idea given that the US is the only advanced country without it, we spend 2-3x as much as those other countries, and generally for equivalent (and often worse) outcomes / level of care. We pay more. We get less. We're unnecessarily putting millions in harms way.

 

In other words... We're just being stupid.

Edited May 20, 2017 by iNow

[KipIngram]

I don't think it's clear that Medicaid is "better." Just the light research I did since yesterday revealed concerns, such as many doctors declining to accept new Medicaid patients, and at least some claims that Medicaid patients in general experience lower quality outcomes. Clearly with the deck stacked the way you just stacked it (it's cheaper, it's better, it wins on every possible criterion), then your conclusion is inescapable. But whether those claims are all true or not is a matter of debate.

 

I certainly agree with you re: the business motivations of insurance companies - I leveled the same complaint about them earlier in the discussion, and expressed support for close government oversight of the industry for that reason. Promises should be kept, and legal prowess shouldn't be used to take advantage of customers. I see guilt on both of those fronts in the insurance companies. In addition, I do not think "arrangements" and collaborations between the insurance companies and the actual providers should be allowed. If I total my car, the insurance company doesn't get to tell me who to buy my next car from. Not a perfect analogy, but hopefully you get the point. I question the whole concept of "networks" that limit your access to providers, etc. A doctor's motivation should not in any way connected to the financial goals of the insurance company.

 

I'm ready to let this go now - I wasn't craving a debate on this to start with, and I can tell that we just have very different fundamental beliefs about preferred societal structures. I do want to show compassion for the unfortunate, and I believe government has to be involved with that in some way (since wealth has to be redistributed somehow). That said, if we have methods A and B that will get us there and A involves entrenched government micro-management and option B involves a "light touch" by the government, then I prefer B. Generally speaking I think "large entities" become bureaucratic, inefficient, and driven by their own internal agendas - and I apply that to large government, large businesses, large churches, and large everything else.

 

You deny any such method B exists, and I disagree. Neither of us is going to change the other's mind.

From here: http://kff.org/medicaid/state-indicator/total-medicaid-spending/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

 

Fiscal year 2016 total Medicaid spending: $553 billion.

 

From here: http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

 

Medicaid enrollment: 74.6 million

 

Dividing, annual cost per person: $7,413 = $617 per month

 

From here: https://resources.ehealthinsurance.com/affordable-care-act/much-health-insurance-cost-without-subsidy

 

"Platinum" level coverage plan monthly premium: $498

Edited May 20, 2017 by KipIngram

[MigL]

Lots of differing opinions on which way the US should go with regards to health care.

My opinion ( interested and somewhat affected Canadian ), pick one, ANY ONE, so that everyone has coverage ( universal ) and run with it.

Deal with the problems as they come up. The US, when it sets its mind to it, has always been able to over achieve.

 

This process of introducing something, the scrapping it and introducing something totally different, only to be repeated with the next administration, makes you guys look silly ( and a little sad )

[Delta1212]

I don't think it's clear that Medicaid is "better." Just the light research I did since yesterday revealed concerns, such as many doctors declining to accept new Medicaid patients, and at least some claims that Medicaid patients in general experience lower quality outcomes. Clearly with the deck stacked the way you just stacked it (it's cheaper, it's better, it wins on every possible criterion), then your conclusion is inescapable. But whether those claims are all true or not is a matter of debate.

 

I certainly agree with you re: the business motivations of insurance companies - I leveled the same complaint about them earlier in the discussion, and expressed support for close government oversight of the industry for that reason. Promises should be kept, and legal prowess shouldn't be used to take advantage of customers. I see guilt on both of those fronts in the insurance companies. In addition, I do not think "arrangements" and collaborations between the insurance companies and the actual providers should be allowed. If I total my car, the insurance company doesn't get to tell me who to buy my next car from. Not a perfect analogy, but hopefully you get the point. I question the whole concept of "networks" that limit your access to providers, etc. A doctor's motivation should not in any way connected to the financial goals of the insurance company.

 

I'm ready to let this go now - I wasn't craving a debate on this to start with, and I can tell that we just have very different fundamental beliefs about preferred societal structures. I do want to show compassion for the unfortunate, and I believe government has to be involved with that in some way (since wealth has to be redistributed somehow). That said, if we have methods A and B that will get us there and A involves entrenched government micro-management and option B involves a "light touch" by the government, then I prefer B. Generally speaking I think "large entities" become bureaucratic, inefficient, and driven by their own internal agendas - and I apply that to large government, large businesses, large churches, and large everything else.

 

You deny any such method B exists, and I disagree. Neither of us is going to change the other's mind.

 

From here: http://kff.org/medicaid/state-indicator/total-medicaid-spending/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

 

Fiscal year 2016 total Medicaid spending: $553 billion.

 

From here: http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

 

Medicaid enrollment: 74.6 million

 

Dividing, annual cost per person: $7,413 = $617 per month

 

From here: https://resources.ehealthinsurance.com/affordable-care-act/much-health-insurance-cost-without-subsidy

 

"Platinum" level coverage plan monthly premium: $498

What is the average deductible for those platinum plans?

[KipIngram]

Good point. It's not given in the "metal level" breakdown. But all the metal levels together had an average premium of $321 per month and a deductible of $4358. So if you assume that is paid every year then you can add it to the cost, which would bring us to ($321*12 + $4358) / 12 = $684 per month, which is about 11% higher than Medicaid. Just using myself as an example, though, I hardly ever actually use my insurance, so I don't hit that full cost level.

 

Looks like Medicaid has a deductible too, as described here:

 

http://www.lawhelpnc.org/resource/faqs-medicaid-deductible

 

Working with a single person, you'd subtract $242 from the person's monthly income and multiplying by six (because Medicaid has a six month certification period). So it would vary widely depending on income. For a person making $1000 per month (very little, that is), the deductible would be ($1000-$242)*6 = $4,548. But that looks to be for the six month period, so that would really be $9,096 per year. To wind up with the same $4,358 deductible as the private plan a person would have to make $605 a month.

[Ten oz]

@ Kiplngram, perfect world start from scratch solutions are seldom possible in an ongoing world. It isn't whether or not the ACA is the best possible answer. It is whether or not the ACA is better (by and inch or a mile) than what we had before and what Congress is looking to change to. The ACA made incremental improvements. It isn't perfect but it is was an improvement. All our nothing in politics doesn't work. Analogy, an air compressor is far and away superior to a hand pump yet both are far and away superior to inflating something with lung power alone. It would be foolish to stick with lung power if offered a hang pump simply because you would've preferred to have been offered an air compressor.

 

Limited or minimal govt is defined differently by every individual. We all want to be masters of our own fates. None of us want govt standing between us and the choices we want to make for our lives. I don't think anyone wants more govt than needed. The argument is over which things are needed. Humans are a group living species and the larger the groups we have and the better governed those groups the more we have thrived. When we were hunter gatherers governance were extremely minimlist. I think some people idealize such an existence. Pure freedom to go out onto the land and make ones own way. Of course it wasn't practical for long term survival of the species. We (humans) repeatedly found ourselves are the edge of extinction. It was coming together in larger groups that allow human to build larger and more solid structures, cultivate land, irrigate, and etc. Living in large groups requires govt. How much govt is required arguably depends on what the collective group is attempting to achieve. The grander the the design the more collective planning and organizing (govt) that is needed. In the U.S. we pride ourselves as the the powerful country the world has EVER had. Pride ourselves as the most influential, the most wealthy, the most free, etc,etc, etc. We have very grand designs and that requires a large robust govt. It simply does no getting around it.

 

So who should be left out? Our Military has govt provided healthcare for themselves and there dependents. That seem pretty necessary. An unhealthy military isn't a very strong one. Diito for the millions of police, fire fighters, and various first responders around the country who have healthcare provided by federal and local govts. How about teachers; are they worth the govt providing them healthcare? They only handle the nations children daily. What about bakers and butchers; they handle our food? Do we keep Medicare for the elderly? Who gets left out. Where is the line in the sand. When is it too much govt vs the needed amount for what the nation is trying to accomplish?

Interesting responses and thank you. Perhaps one of the many dangerous points of view is to imagine something that is simply not there. Again, the US Constitution means what it says and says what it means. Very simple language that still is understandable today. Particularly today. To imagine it meaning something else to suit ones liberal fancy is very hazardous. The Constitution is NOT a living document

 

The 10th Amendment also is very simply stated. Presented arguments here stating that "that ship has sailed" and related "living document" points of view, (thank you) fail. You can not imply something that is not there. Mandated National Health Care is very dangerous. Such mandates must come from the States respectfully OR ... from the individual desiring such health care. If you want something, YOU pay for it.

 

Respectfully.

The Constitution empowers our govt to create laws, departments, taxes, and etc. It even empowers govt to amend the very powers it outlines. The Constitution has been amended 17 times.

[KipIngram]

Well, technically 27, but yeah, the first ten do sort of stand out.

 

HB of CJ: Personally I'd actually prefer a narrow interpretation of the Constitution, but that's not the way things have worked out. I was just trying to bring a "realist" perspective to hte discussion. But I don't really disagree with you on that.

[Ten oz]

Well, technically 27, but yeah, the first ten do sort of stand out.

 

HB of CJ: Personally I'd actually prefer a narrow interpretation of the Constitution, but that's not the way things have worked out. I was just trying to bring a "realist" perspective to hte discussion. But I don't really disagree with you on that.

The first 10 we there when it was fatified. 17 were amended after.

[KipIngram]

https://constitutioncenter.org/blog/the-day-the-constitution-was-ratified: Constitution ratified June 21, 1788.

http://www.americaslibrary.gov/jb/nation/jb_nation_bofright_1.html: Bill of Rights adopted December 15, 1791.

The inclusion of much of the content of the Bill of Rights in the main body of the Constitution was proposed and discussed, but in fact that wasn't the path taken.

Twelve amendments were originally included in that first batch, but two didn't make it. One would have had to do with the size of the House of Representatives (ensuring that it would never be too small compared to population) and the other would have made Congressionally approved pay raises for Congressmen effective only after the following election. Interestingly, it is that second amendment that was eventually passed as the 27th amendment - no window on ratification was specified, and in 1982 a student named Gregory Watson recognized this fact and was able to rekindle it. It was eventually ratified in 1992. That's documented here:

 

http://teachinghistory.org/history-content/ask-a-historian/21861

[iNow]

I can tell that we just have very different fundamental beliefs about preferred societal structures.

(...)

I f we have methods A and B that will get us there and A involves entrenched government micro-management and option B involves a "light touch" by the government, then I prefer B. Generally speaking I think "large entities" become bureaucratic, inefficient, and driven by their own internal agendas - and I apply that to large government, large businesses, large churches, and large everything else.

 

You deny any such method B exists, and I disagree. Neither of us is going to change the other's mind.

 

Just to clarify, I don't deny option B exists. More precisely, I'm saying we've tried it with healthcare and it's failed. Others have tried it with healthcare and it's failed. Those who have moved to UHC / single payer, however, have radically decreased costs, increased coverage, and outcomes have not suffered as a result. Seems we should pull our collective heads out of our butts and borrow ideas from those who are doing this well.

 

On another note, I would change my mind if a quality counter argument were presented. I've done it many times here and elsewhere through the years. Keep in mind how long I've been a member here and how many posts I've put forth. This isn't exactly my first healthcare discussion, and there are few ideas I've not yet seen or considered. That doesn't mean I refuse to listen or that I'm too stubborn to change.

 

Thanks for engaging in the exchange. You've been both respectful and kind with your ideas. I've enjoyed it and appreciate your views.

 

 

[mp][/mp]

Kip sent me the following link via PM and asked for my thoughts... sharing my reply here so the discussion can continue in the open >> https://www.cagw.org/media/wastewatcher/veterans-administration-socialized-healthcare-system

 

-------

 

Interesting article. Lots of good points, though some I feel are framed poorly / ignore rather important context.

 

The VA situation, for example. The article suggests those failures are due to the concept of UHC, but the more business minded explanation is Congress treats everything like a cost instead of seeing some things as investments with clear return. As a result, they failed to scale supply properly with demand. It was a failure in forecasting and funding, not a structural flaw with UHC or single payer systems in general.

 

In other words, we fought two wars in Iraq and Afghanistan, sent hundreds of thousands of our friends to fight and get injured, but didn't in parallel ramp up VA staffing by hiring docs and nurses and schedulers or adding facilities to be ready for when troops came home and needed care. Instead, the "we must cut taxes always and forever" mindset caused us to disinvest and screw our troops who earned that care at great risk to themselves. It's like trying to feed 300 head of cattle with a single bail of hay... the problem is not with the hay.

 

Invest in scheduling systems. Invest in hiring staff. Do those things and the VAs problems get quite a lot better pretty quickly...also we need adjust the incentives so Ops reports are no longer lying to superiors about actual wait times, but I digress.

 

You said the free market is best for cost containment and efficiency. In many cases, you're right, but not in healthcare. As I shared, this market is not free and patients lack enough information to shop around... they also are at the mercy of their docs who may order tests they don't need, but us the patients... the consumers... are fundamentally handicapped there since we don't know as much as the doc. They're the ones with 8 years of advanced schooling. We need to trust their judgement.

 

Not to mention that you can't ask the driver of an ambulance to take you to a different hospital when you've had a heart attack or been in a car accident... you can't refuse the MRI when you're unconscious or ask the phlebotomist to use a different syringe that's cheaper. Free market principles are too simplistic for this space and it's naive to think healthcare is a good place to apply them. We have mountains of evidence, stories, and counter examples in support of this point.

Edited May 21, 2017 by iNow

[swansont]

I don't think it's clear that Medicaid is "better." Just the light research I did since yesterday revealed concerns, such as many doctors declining to accept new Medicaid patients, and at least some claims that Medicaid patients in general experience lower quality outcomes. Clearly with the deck stacked the way you just stacked it (it's cheaper, it's better, it wins on every possible criterion), then your conclusion is inescapable. But whether those claims are all true or not is a matter of debate.

 

 

If medicaid were the only game in town the issue of accepting new medicaid patients would change quite dramatically.

[KipIngram]

Well, yes - can't argue with that. But that implies that not only are we trying to help people of limited means, we are also prohibiting people from exercising in free choice. I guess some people are okay with that and some are not, but it's clearly less desirable than an approach that accomplishes the necessary goals while still leaving people free to choose whether or not to partake of the benefit. Given the choices of a) prohibiting everything other than Medicaid or b) funding Medicaid to a level that allows it to overcome issues like doctors turning away Medicaid patients, I'd very much prefer the latter. Maintenance of freedom is worth paying for, at least to me.

[swansont]

Good point. It's not given in the "metal level" breakdown. But all the metal levels together had an average premium of $321 per month and a deductible of $4358. So if you assume that is paid every year then you can add it to the cost, which would bring us to ($321*12 + $4358) / 12 = $684 per month, which is about 11% higher than Medicaid. Just using myself as an example, though, I hardly ever actually use my insurance, so I don't hit that full cost level.

 

But other people exceed it, which is the whole point of insurance.

[KipIngram]

Yes, I understand. My point there was than in order to properly incorporate the deductible into the overall cost of the program you'd need data on how much of the deductible was actually spent, per year, on the average. Adding the whole deductible to the annual cost, every year for every person, is the worst-case scenario.

[swansont]

Insurance also covers some percentage of the bill, exclusive of the deductible. You have to account for that as well.

 

AFAIK medicaid has limited out-of-pocket expenses

[Delta1212]

Insurance also covers some percentage of the bill, exclusive of the deductible. You have to account for that as well.

Not if you're comparing the end user costs of the system. Any money paid out by the insurance company has to be paid in by customers unless the company is in the red, so you're already accounting for that amount in the monthly payment figure.

 

What you need to compare to see relative expenses of private insurance healthcare vs government insurance is how much people spend on their insurance payments + how much they spend themselves on healthcare, and then compare that to the total tax figure used to cover all of the people on government health insurance + anything they spend on healthcare.

[iNow]

that implies that not only are we trying to help people of limited means, we are also prohibiting people from exercising in free choice. (...) Maintenance of freedom is worth paying for, at least to me.

The concept of freedom in healthcare is an interesting one. This piece aligns with my thinking on the matter. A short snippet below, but the larger article is worth a quick read.

 

https://www.nytimes.com/2017/03/18/opinion/the-fake-freedom-of-american-health-care.html

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.

 

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom.

(...)

As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom. So is the freedom of knowing that none of it will bankrupt us.

(...)

If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America’s corporations and businesses to streamline their operations, releasing them from bureaucratic obligations

[KipIngram]

I think what swansont meant (swansont, please correct me if I'm wrong) is that even after you've paid your deductible insurance only pays X% of the remainder for some services, so the (100-X)% also has to come out of the customer's pocket and would add to the total. He's right about that, but that varies all over the place and I'm not sure how to calculate it without getting the details of some plan in front of me and crank numbers. In addition to that the plans usually have a maximum out of pocket, so there's an upper limit to that effect that would have to be factored in as well.

 

Summing up some things, I think we've identified three different approaches to providing health care for those who can't afford it on their own: 1) give them money (or vouchers, or whatever) and let them buy insurance on the open (private) market, 2) operate a plan like Medicaid in parallel with the private healthcare system, and 3) mandate that something like Medicaid is the only system allowed, and everyone relies on it. I would love to think that option 1 could work for a reasonable cost (even if it's some percentage (10-40, say) more expensive than option 2. Option 3 seems much, much more invasive to me - it goes beyond simply taxing me (a cost I am more than willing to bear) in that it tells me, someone who has managed to not need government assistance, that I'm not free to handle my healthcare in any way I choose. The big reason I like option 1, even at a higher cost, is that it makes all of the people it helps "just as free as me" - they are equipped with funds with which to shop the same market I shop, and that market will view them no differently from the way it views me. It makes them my equal within the healthcare market.

iNow: Those are nice words, but if in fact options that are available to me now are not available to me under some other plan, some of my freedom has in fact been taken away, whether that was "the point" or not. I'd much prefer to focus on giving those freedoms to everyone.

Edited May 21, 2017 by KipIngram

[iNow]

Yes, everyone should be equally free to be unable to afford their healthcare. I'm well familiar with the GOP stance.

[KipIngram]

Except that's not what I'm saying. I'm not trying to defend the status quo; I've been trying very hard to talk about new things we could actually do to make healthcare available to everyone. It's how I feel about poverty-related issues in general; I truly believe that a nation as rich as ours could lift everyone above some meaningful poverty line if we implemented the right sort of approach.

 

I just believe it's at least possible that we could do so with a minimum of government intervention outside of the tax code.

Edited May 21, 2017 by KipIngram

[swansont]

Not if you're comparing the end user costs of the system. Any money paid out by the insurance company has to be paid in by customers unless the company is in the red, so you're already accounting for that amount in the monthly payment figure.

What you need to compare to see relative expenses of private insurance healthcare vs government insurance is how much people spend on their insurance payments + how much they spend themselves on healthcare, and then compare that to the total tax figure used to cover all of the people on government health insurance + anything they spend on healthcare.

 

That was my point. If my premium covers 80% of my costs, it's not correct to compare it with a plan that covers 90%. All else being the same (deductible, co-pay), my plan will be cheaper, and for good reason.

[Delta1212]

Except that's not what I'm saying. I'm not trying to defend the status quo; I've been trying very hard to talk about new things we could actually do to make healthcare available to everyone. It's how I feel about poverty-related issues in general; I truly believe that a nation as rich as ours could lift everyone above some meaningful poverty line if we implemented the right sort of approach.

 

I just believe it's at least possible that we could do so with a minimum of government intervention outside of the tax code.

The major problem is that the only way that 1 works from a cost efficiency stand point is if everyone who chooses not to buy health insurance at all is simply refused service in an emergency unless they can cover the expense in full or qualify for a loan ahead of service being performed.

 

Requiring hospitals to provide expensive services to non-paying customers drives up costs considerably and prevents efficient allocation of resources.

 

The point of insurance is to pool risk. If there's a 1/100 chance of me needing $100,000 care, I can get together with a group of 100 people and we each pitch in $1,000 and now I know exactly how much I have spent on health care and can plan around that much less burdensome amount. I probably won't end up needing it, but all of us get the peace of mind of knowing that we're on steady financial ground no matter what.

 

If, however, someone who didn't join our pool gets sick and the hospital has to perform the procedure and can't recoup the expense, then suddenly the $100,000 procedure for one of us becomes a $200,000 procedure and now we each need to kick in $2,000 to cover our own costs and the cost of the other person.

 

But now the risk pool has failed, because we're paying higher rates than our level of risk would dictate, and the risk itself is much reduced because not being in the pool still allows me to have my costs covered by those remaining in it in the event that it ever becomes an issue.

 

And then even if hospitals simply straight up deny care to those who can't afford to pay through insurance or otherwise to keep costs down for those who can, you have the issue of pre-existing conditions. Because if my pool allows someone to buy in who is already sick, it comes out to being the same as the above example. Statistically, one of us is still likely to need the $100,000 from our pooled resources, and now there is an additional person who is guaranteed to need it, so we need to increase the buy in to $2000 to cover that cost.

 

 

So if you want to control overall costs, you need to figure out what to do with people who are already sick and are therefore a losing bet for private insurance to cover, and people who choose not to get insurance and therefore aren't paying into cover everyone's costs.

 

Those are two of the primary obstacles to the distribution of healthcare through private insurance.

[KipIngram]

The major problem is that the only way that 1 works from a cost efficiency stand point is if everyone who chooses not to buy health insurance at all is simply refused service in an emergency unless they can cover the expense in full or qualify for a loan ahead of service being performed.

 

Yes, that's the line of reasoning that leads to a mandate. I think my option 1 is neutral on that point - you've given people the financial means to afford health insurance on the open market - whether you also require them to is a separate issue. I think you have a valid point; if there is not a mandate then some people will opt out and take a vacation or something instead (or just fall prey to poor budgeting). I don't think we can have that one both ways - I think we either have to have a mandate or do just what you said: turn people who opted out and can't pay away. I feel fairly sure we'd go with the mandate. It sounds harsh, but on the other hand we all have a mandate to buy food - it's just a biological mandate instead of a government mandate. I'm required by my state to carry car insurance in order to legally operate a car on the public streets. So as much as people moan and groan about it, there is precedent.

 

Pre-existing conditions are a problem no matter what. I think that ties in with a mandate too - if you are going to force the insurance companies to accept anyone, then you probably also have to force people to own insurance.

 

So, yeah - I'm not going to claim that we can "have it all" - fully private industry, no mandate, guaranteed acceptance regardless of pre-existing conditions. That just won't work. And I do want to say again that my support for a minimal government intervention approach does not mean I admire the way insurance companies operate today. I think most of them are pretty despicable, when you get right down to it, and will happily screw people over for profits. I don't think that can be fixed without government regulation and oversight.

iNow: Just so you know, I am actively thinking about this from as many different angles as I can, trying to give every perspective a fair shake. For example, just now I was thinking about how emergency room service is really "different" from when I go in to see my doctor for a regular checkup. ER service is rather like having your house catch on fire, and I don't sit around thinking about how we should have privatized fire departments. Is it possible that there's more than one situation in play here, and that the different "types" of service might be addressed in different ways?

 

Like, what about discretionary surgery, for example? Totally superficial things, like cosmetic surgery? Cosmetic surgery is "required" in very few cases - it's usually a vanity thing that doesn't really need to be done at all. So I certainly don't think the government should be footing the bill for things like that. That's one extreme, whereas life-and-death trauma such as that faced in emergency rooms is the other extreme.

[iNow]

The fire department example is a good one. My position is that the fire department should be in place for everyone. No matter where you live, what job you have how wealthy or how poor... there's a minimum level of security we afford you due merely to your existence within an advanced civilization.

 

Now, should you want to supplement that minimum fire department coverage with smoke detectors, hoses, sprinkler systems, escape hatches, and fireproof bunkers, then great! Nobody should stop you. That's your preogative and you are free to move forward in any way you desire with all that awesome Batman style supplemental swag... but before that we should ALL have access to AT LEAST the fire department.

 

Health insurance is the same. There are some lowest common denominators we should guarantee to all. We should treat healthcare no differently than fire departments, and if folks wish to supplement that minimum level of health coverage and protection from the government with private insurance on top (maybe for nose jobs and liposuctions or whatever else), then good on ya! Alternatively, just pay out of pocket.

 

We then merely need to agree on the thresholds of what us and is not included... what maximizes outcomes and minimizes waste... and it's hardly like we're the first people on the planet ever to explore this. We can borrow the best ideas from the countless other nations who have already struggled with and addressed these hard questions.

Edited May 22, 2017 by iNow