Health Care Reform

[Kbg]

My sense, let’s say the next 5 yrs, is that something major is going to happen with healthcare in the US. The system is simply not sustainable as it is and people, for good or bad, are willing to go with something radical.

[Kriegsspiel]

The current Medicare-For-All bill reportedly proposes to ban private health insurance, which even the Canadian Supreme Court ruled was a human rights violation. A former aide for Chuck Schumer went on Tucker's show and argued that that was just a starting point, because Americans used to "meet in the middle" LOL.

When your starting point in a negotiation has been ruled a human rights violation.

[D1984]

This article about a ridiculously expensive ER bill for treating a cat bite came up on the Apple news feed:

Total bill: $48,512, with $46,422 of that total for one preventive medication

Medical service: Parker's wound was examined, and she received the first in a series of rabies shots, as well as an injection of 12 milliliters of rabies immune globulin, an antibody that kick-starts the immune system to provide protection from the virus until the vaccine kicks in.

...

Alvarez also noted that the month after Parker was treated, Mariners revamped its full price list, known as a "chargemaster." The hospital lowered its charge for rabies immune globulin to $1,650 per 2 milliliters, which would have made Parker's bill about $9,900 — still high, but not sky-high.

Hospitals revisit their chargemasters periodically. But it should be noted that this particular 79 percent cut came shortly before January, when new rules required all hospitals for the first time to post those previously hidden charge lists publicly on websites, part of the Trump administration's interpretation of the Affordable Care Act.

https://www.npr.org/sections/health-sho ... lls-48-512

So nice to see price transparency doing its job. Simply making it embarrassing for hospitals to mark up items to indefensible levels is going to work wonders. There are now articles directly comparing prices for procedures among nearby hospitals, which might well result in people choosing hospitals accordingly.

I might also point out that, even though I share everyone's worst opinions of Donald Trump as a person, the fact is that his unsung accomplishments like requiring that hospitals post their charge lists comes as part of the package. Correct me if I'm wrong, but I don't remember anyone else in Washington seriously talking about hospital price transparency.

Technically it wasn't Trump that did it; I believe Seema Verma and Alex Azar (which since they were his appointees...credit to Trump where where credit is due) were the ones behind this. With that said; IIRC what happened was that CMS simply issued a regulatory reinterpretation of a section of the Affordable Care Act that had since 2014 required hospitals to make available a list of their chargemaster prices upon request; the new interpretation of this part of the ACA by Trump's CMS says that as of 1-1-2019 hospitals have to post it online or at least make it available in machine-readable format and they have to do so pre-emptively, without first being asked.

See: https://healthpayerintelligence.com/new ... ary-1-2019 and https://www.sheppardhealthlaw.com/2018/ ... inal-rule/

I also don't have your confidence that merely requiring them to post the chargemaster prices will do much. It may work somewhat in places like NYC where there are many hospitals competing in a very small area but (for example) where I live there is one hospital system that is a monopoly until you go around 32-60 miles (depending on which cardinal direction you head in) and even when you go to one of those other cities that are 35 or 41 or 59 miles away the hospital systems in those cities are virtual monopolies too (the one at almost 60 miles away does have a small private hospital competing with it but they are rather picky about what insurance they accept and if I recall correctly have limited ER facilities). Not particularly helpful if you have a medical emergency and need to get to the closest facility ASAP, or are a single parent working two or three jobs with very limited time to travel almost an hour, or don't have a car, etc.

What would help more is a bill like ochotona suggested...or barring that do what Maryland does and mandate that Medicare, Medicaid, private insurance, the uninsured who pay cash, etc, all pay the same rate, or at least do what New Jersey does and don't allow hospitals to charge any of the uninsured--or at least those uninsured who make up to 500% of the poverty line anything more than Medicare rates + 15%.

Of course, what would REALLY help would be single-payer Medicare-for-all and use the government's negotiating clout and monopsony buying power to get rates down to as low as possible but where hospitals can still at least break even.

[D1984]

The current Medicare-For-All bill reportedly proposes to ban private health insurance, which even the Canadian Supreme Court ruled was a human rights violation. A former aide for Chuck Schumer went on Tucker's show and argued that that was just a starting point, because Americans used to "meet in the middle" LOL.

When your starting point in a negotiation has been ruled a human rights violation.

They wouldn't actually need to ban private insurance; simply do what New York did (and Oregon did at one time too) and mandate that all private health insurance be guaranteed issue and community rated with little or no limited open enrollment period (i.e. people can enroll right before going to the ER, enroll as soon as they find out they are pregnant, enroll as soon as they find out they have cancer, etc). For the cherry on top do like some states did with LTC policy rates (I'm looking at you, Pennsylvania) and refuse to allow premium increases even when actuarially completely justified. Voila, within a few years at most you have an adverse selection actuarial death spiral and soon there will be no private insurance.

In all seriousness, though, It seems the Dems have finally gotten the lesson that you don't start negotiating from where you want to finish at; you start with a pie-in-the-sky "If I was king of the world this is what I'd do" progressive's wet dream and you negotiate down from there. If you start from the absolute center on healthcare and negotiate down from there, you end up with.....<drumroll for effect>.....Obamacare.

[WiseOne]

Good for Texas, indeed!!! Hope other states take note. And D1984, if you read the article I posted (and the quote from it) you'll see that the chargemaster posting requirement has already resulted in a large cut to a clearly indefensible charge by that hospital. I also read a local news article directly comparing prices for a common procedure among several nearby hospitals - which is a great thing for journalists to do, if they can take time away from their People magazine-like treatment of the US government.

Medicare for all seriously needs to happen, but I'll be interested to see the proposals for how to pay for it. Adding 4% to the current Medicare tax is probably a fair way to do it and certainly the simplest and most logical, but unfortunately the Dems seem determined to bind this already hot button issue up with the recent manic desire to sock it to the rich. Which brings up the question of how you define "rich".

This document on Bernie Sander's website gives at least his answer to that question: Rich = $250,000 "household" income, which I take to mean married filing jointly. That would presumably translate to an income of $125,000 for a single person. Doesn't sound rich to me, but it's all so subjective. In NYC that gets you a comfortable but not luxurious middle class lifestyle. In Vermont it may be regarded as rich.

https://www.sanders.senate.gov/download ... nline=file

[Xan]

One big thing for me with your "Medicare for all" plan, WiseOne, is whether or not people can use some of that money to go find and pay for their own care.

In other words, if it's like public schools, where everybody has to pay for the public schools and then on top of that pay for a private school if you want, then no thanks.

If it's like a school voucher system, where I can use the money I would have paid the public school towards whatever education I choose, then maybe.

[Kriegsspiel]

One big thing for me with your "Medicare for all" plan, WiseOne, is whether or not people can use some of that money to go find and pay for their own care.

From what I've seen, the bill bans private plans that duplicate Medicare's coverage.

[jacksonM]

One big thing for me with your "Medicare for all" plan, WiseOne, is whether or not people can use some of that money to go find and pay for their own care.

From what I've seen, the bill bans private plans that duplicate Medicare's coverage.

I think somebody needs to define "Medicare for all" when they talk about this.

There is Medicare part A which is free at age 65 and pays a portion of hospital bills only, part B for which a premium is paid and includes doctors visits with co-pays. Then there is part D which includes coverage for prescription drugs, also with a premium and co-pays. My parents also had a medicare "advantage" policy which I don't know much about except that it paid nearly all but $2,500 of the $660k bill my mother accumulated during her recent 3 week end-of-life stay in the hospital.

So what do they actually mean when they say Medicare for all? My guess is that they don't really mean to put everybody into this system. I'm guessing what they are really talking about is free health care for all which is not medicare as we know it. And I think those who are proposing it probably know it too and are just trying to trick us.

[Xan]

One big thing for me with your "Medicare for all" plan, WiseOne, is whether or not people can use some of that money to go find and pay for their own care.

From what I've seen, the bill bans private plans that duplicate Medicare's coverage.

I think somebody needs to define "Medicare for all" when they talk about this.

There is Medicare part A which is free at age 65 and pays a portion of hospital bills only, part B for which a premium is paid and includes doctors visits with co-pays. Then there is part D which includes coverage for prescription drugs, also with a premium and co-pays. My parents also had a medicare "advantage" policy which I don't know much about except that it paid nearly all but $2,500 of the $660k bill my mother accumulated during her recent 3 week end-of-life stay in the hospital.

So what do they actually mean when they say Medicare for all? My guess is that they don't really mean to put everybody into this system. I'm guessing what they are really talking about is free health care for all which is not medicare as we know it. And I think those who are proposing it probably know it too and are just trying to trick us.

No doubt. I'm sure the phrase "Medicare for all" is simply the version of "nationalized healthcare" which focus-grouped the best.

Also keep in mind that your mom's sticker price is not anywhere close to what the actual cost was: it isn't what Medicare paid, nor is it what she would have paid without insurance. The real cost was probably on the order of $66k. Okay, that number is a wild guess; maybe somebody else more knowledgeable could come up with a better one.

[boglerdude]

> Loooong waits to see specialists and have surgery are the norm there.

Thats good, as long as you have the option to buy private insurance for faster service (but they cant). Freeways should be the same, slow free lanes and fast toll lanes

[WiseOne]

It's supposed to be an "expanded Medicare program with improved and comprehensive benefits". So presumably all parts.

Xan, what care do you think you can get now but can't under a plan like this? Currently if you're not paying cash, you have to seek permission from your insurance company (it's called "prior authorization") in order to get certain tests, procedures, and medications. Medicare is much less restrictive than private insurance, in fact. It doesn't do prior auth. Its main tool for controlling costs is to limit reimbursements. I expect boutique/concierge practices will not change under a Medicare for all system.

Everybody always brings up Canada which is a completely silly comparison. First, I happen to know several Canadian physicians. Yes, the wait for routine specialist care can be long, but urgent/emergent stuff happens as quickly as it does here. And, routine care here is often delayed so much by insurance company red tape that you effectively have wait times here too. Second, in Canada health care spending is constrained to less than half of what we spend per capita here in the US. They've got fewer doctors, way fewer specialists, and fewer facilities. If they increased their spending to US levels, that would take care of the bottlenecks.

There's no proposal here to decrease our medical spending, though of course that could happen later. It's a separate debate that may one day be worth having. Instead, the goal is to save money (about $600-700 billion) by eliminating the administrative inefficiencies built into our current system. Medicare's overhead is a tiny fraction of what private insurance companies have and inflict on the rest of the system.

One thing that I hope will change also: Medical care here is increasingly focused on milking as much money as possible from every patient, to the point where I really question whether anyone is getting "medical care" as opposed to "oh goodie, you have symptom/condition X. I can order you up a pile of treatments and tests that will mollify the bean counters who are on me every day to work harder for the same pay to earn more money. Never mind if you actually need them." I'm not sure this would change, but having fewer administrators to deal with couldn't hurt.

[WiseOne]

I think that may have been true years ago, but that's not what's driving it now. It's a combination of top-heavy administrations trying to squeeze more productivity from the proletariat (i.e. doctors) because that's your standard business model, and a "the customer is always right" mentality.

[Xan]

Xan, what care do you think you can get now but can't under a plan like this?

The concern I'm raising isn't one about not being able to get care, it about (like the public schools) having to pay for BOTH the bad, "free" care AND the good care I would actually want. Instead of (like the school vouchers) being able to take [some of] the amount I contributed to the "free" care and use it towards the good care.

[WiseOne]

If it's a straight up switch to Medicare, the care wouldn't look any different from the viewpoint of a patient than it does now. The differences would be in the insurance premiums you pay and the bills you get afterwards. It's sort of like what will happen when you turn 65. You won't suddenly start getting "bad care". In fact, here's two problems you have now that will immediately go away: 1) no more in-network vs out of network headaches, and 2) your doctor says "before we can do this <procedure/test/med>, we have to get prior authorization from your insurance company."

There are a lot of details missing to be sure, like what's going to happen to Medicaid (currently 1/3 of NYS's budget, and a linchpin of the medical education system.) Sounds like the bills's sponsors are severely underestimating the complexity of what they've taken on. Kinda knew that, but I still like the idea and it could work if done right.

[Xan]

Okay... Except I don't have any of those problems now, because I'm paying for everything myself rather than through insurance. So when it's "free", it doesn't do anything except get more expensive, right?

[Kriegsspiel]

I think when a Democrat is starting from the position of "you can't have your own insurance, neener neener comrade!" it would be fun to see someone call their bluff. Really get wild with the Overton Windows.

"Fine. We accept. On one condition...

We release panthers, into every city, to cull the weak. None of those juveniles either. Adult predators. Also gun sales will be frozen from now until 3 weeks after The Releasing."

[Dieter]

Medicare for all seriously needs to happen....

Be careful what you wish for. You should talk to some Canadians before thinking that this is a good idea. Loooong waits to see specialists and have surgery are the norm there.

Long waits to see medical folks here in the US as well.

[WiseOne]

Okay... Except I don't have any of those problems now, because I'm paying for everything myself rather than through insurance. So when it's "free", it doesn't do anything except get more expensive, right?

If you're self-paying I assume you're talking about routine office visits and labs - but realize you're still paying for the insurance-imposed bureaucratic structure that surrounds these visits nows. Definitely agree that putting these outside the purview of insurance would reduce their costs and end up improving services. Having just one insurance agency with a simple billing structure to deal with, though, would be way better than the mess we have now and would also reduce costs - just not by as much.

Interestingly, the rapidly expanding world of telemedicine is pretty close to the self-pay utopia you're thinking of. Visits are in the $40-50 range and you pay for extra time if you're the type who just has to talk for 45 minutes nonstop, no need to deal with waiting rooms and getting to the office, and services are springing up everywhere. Watch for these to replace the phone calls that are the bane of every office practice's existence.

[jacksonM]

Medicare for all seriously needs to happen....

Be careful what you wish for. You should talk to some Canadians before thinking that this is a good idea. Loooong waits to see specialists and have surgery are the norm there.

Long waits to see medical folks here in the US as well.

I have a lot of Canadian friends and have visited there many times. When asked about their health care system, I've yet to hear one person complain about it. Actually, most of them seem to be proud of the fact that their system is so much better than ours.

[InsuranceGuy]

[deleted]

[Kbg]

Totally cool with above recommendations...and while we are taking things out, no limited liability corporations are allowed to engage in providing medical services.

[jacksonM]

If you're self-paying I assume you're talking about routine office visits and labs - but realize you're still paying for the insurance-imposed bureaucratic structure that surrounds these visits nows. Definitely agree that putting these outside the purview of insurance would reduce their costs and end up improving services. Having just one insurance agency with a simple billing structure to deal with, though, would be way better than the mess we have now and would also reduce costs - just not by as much.

Insurance-imposed bureaucratic costs are way lower than government-imposed costs. Please review the billing structure of Medicare/Medicaid if you think somehow they are winning. Better yet compare your benefits to government benefits and then visit your local DMV or Post Office to observe who we are spending these spectacular benefits on. I personally don't understand how we can trust a government to be efficient who has so consistently failed to perform as such.

One of my daughters and one of my grandsons are currently making their living off of the "Insurance-imposed bureaucratic costs" of private health insurance. They both handle pre-authorizations for services on the phone. My daughter has even become a supervisor and is making some decent money for the first time in her life.

So obviously I can't help but wonder what the impact of "Medicare for all" is going to have on their careers and how they handled this economic disruption in Canada when they transitioned to a government run system. Lots of people will be similarly affected, including my wife who is a licensed medical technologist working in a lab. Unlike my daughter and grandson, there will still be a need for people to do her job but there is no guarantee it will be her. Fortunately, I've been trying to talk her into retiring any way.

I tend to think all three of their jobs will eventually be eliminated any way however, if not by the government, then by automation so it's anybody's guess which will come first.