AHCA

[akiva]

Am I the only one is constantly checking news sites to see if this thing is going to pass?

[Tahlvin]

Checked the news once over lunch break, but otherwise haven't looked.

[Cazmonster]

Ryan has done a presser saying this congress is going to move on. Check VOX on facebook. That's where I'm about to watch the victory dance.

Now that Trump's ultimatum has failed and he's tried to make the House look like garbage, how far away is that Special Prosecutor into the Russia treason garbage?

[Phoebe]

Conor Friedersdorf at the Atlantic has a good point about how Fox type media are largely to blame for this debacle. When you lie to people so much for years, it turns out they might be shocked to discover even partial truths. Yes, yes, Obamacare is a disaster robbing us of all our Constitutional rights, but obviously I want my 21 year old kid on my insurance, and my pre-existing condition and preventative mammogram covered. Oh wait, what? The people I really do NOT get are people covered only because they had Obamacare who didn't think it was Obamacare due to the name.

[akiva]

Well the death panels would have gotten my dad if he hadn't first died in the the Bowling Green massacre.

Thanks a lot, Obama.

[Phoebe]

Wow, your poor Dad. Luckily I was given a rating of "positive use value" by the state, so for now I'm being encouraged to avoid euthanasia. Perhaps the thing that enrages me most about the Sarah Palin and other Republican type b******* lies about Medical Care is that a lot of people desperately need access to palliative end-of-life care, and even euthanasia where appropriate, and are unable to get it. Because of Republicans. And I mean specifically because of Republicans. Justice will only arrive if the people who insist on making these choices for others in their total ignorance of medical facts would get pancreatic cancer and die a prolonged and painful death because they were unable to make any other choice.

[Phoebe]

I gather Bernie Sanders is going to put forward a single-payer health care option, not that I expect it to pass, but it's an interesting contrast with the alternatives. Here's what I don't understand, and I know Tahlvin is an expert in these things and others know more about insurance and such: if we're going to deny people coverage for preexisting conditions, or charge them rates as if they were seeking car insurance with a long history of damaging wrecks, why wouldn't it be better to simply get rid of all this extra layer of insurance and go to the single payer system? What are the actual pros and cons? Since you don't often get those pros and cons spelled out particularly fairly by any partisan of a solution, I'm lost.

My employer has a group policy that is then part of a larger BCBS nonprofit manager of the insurance. If lots of people have expensive problems, it's directly reflected in our costs. Sometimes we get a rebate because everyone has lower bills. The preventative care is absolutely essential to saving money. Suppose we hated each other and didn't care if those with pre-existing conditions died without health care, or had to spend all their money on it and go bankrupt. How much would it solve for us financially, considering that many of the people I know at work who had long and difficult health care struggles had no preexisting conditions that would have indicated such events? Surely some of the employees DO have problems related to the pre-existing conditions. On the other hand, since we give pretty darn good preventative care coverage, isn't it in some ways better to know that someone has, say, diabetes or the risk thereof? Or a TIA that warns of a stroke before one would happen? We already know X number of people are doing to die of problems related to these things, preexisting condition warnings or not. So doesn't it in a sense help us to know about it beforehand and ensure prevention and treatment are covered? Wouldn't that reduce the number of people needing more serious interventions?

Anyway, my libertarian economist friends are like, nah, you cannot demand pre-existing conditions be covered and still expect insurers to be able to compete and offer coverage that works for other people. But isn't this just the whole problem? We are shunting those people off to the taxpayer or making some monstrous moral failure, all so that the insurance companies are protected? That seems ... deeply wrong. I just don't get it. And people have explained it to me but they never account for any of those problems.

[Bonefish]

Whack your libertarian friends in the head with a trout. They deserve it. I used to be one, I would know.

What what I can tell, the pros of single-payer is that it cuts out the middle-man of insurance. We all pay into it as taxpayers, and when we go to the doctor, the doctor bills the government agency, and that's it.

The con, so far as I can tell, is that it we pay higher taxes.

[Tahlvin]

Now you're getting into some differences between group vs. individual insurance.

With group insurance, especially group insurance for larger employers, the insurer is guaranteed that pretty much everyone in the group is going to participate. They know some people will be healthy and some will not, some will have pre-existing conditions and some will not, but it's a large, mostly-stable population, and the cost can be spread equally among all of that population. There isn't as much of a concern about the pre-existing conditions because there's enough healthy people to subsidize the care of those people.

For individual insurance, particularly before the insurance mandate, the pool of insured people is not as guaranteed. If the insurance gets to be expensive, the healthy people (and yes, the poor people) decide to go without insurance rather than pay the premium, so the people who end up buying the individual insurance are the people expecting high costs: the chronically sick, those with pre-existing conditions, people expecting high bills in the near future (planned pregnancy), etc. This can result in the death spiral you're heard bandied about: with not enough healthy people in the pool to subsidize the care of the sick, the cost per person in the pool rises, which means premiums rise, which means more poor or somewhat healthier people drop out of the pool, which results in the cost per person remaining in the pool rising even more, etc., etc.

I'm not sure what exactly people expect single payer healthcare to achieve by itself. Right now, one of the big ways the insurance companies compete with each other, and (at least in theory) help control healthcare costs, is by offering a network of doctors and hospitals where they have negotiated advantageous contracts. If there's only one payer in the market, they're not competing against each other to negotiate those contracts, so the cost for care is either set across the board by the doctors and hospitals, or it's dictated to the doctors and hospitals by that single payer. That latter approach is the approach currently taken for Medicare, where Medicare dictates what they'll pay for each service, and it's well below market average for that same service from non-Medicare members, so many doctors have a limit to how many Medicare patients they will take on to their practice. And if you leave it to the doctors and hospitals to set the rates, well, I've already talked about how for-profit hospitals are a big contributor to high healthcare costs that generally get ignored in favor of bashing the insurance companies. Allow the single payer to dictate what they'll pay, and you'll just end up with another tiered healthcare system, where the rich will buy their own doctors (boutique healthcare!) and pay the doctors whatever they want for providing preferred attention, service and quality, while everyone else is stuck standing in line waiting to find a doctor that will accept them. It's a bit of hyperbole, yes, but some of it is already happening.

I've been giving it a bit of thought, and here's my pipe dream I'd love to see for true healthcare reform:
1) Eliminate employer-sponsored health insurance. Take everyone, whether employed through a large employer, self-employed, or a contractor, and place them all in the same individual insurance market and pool. Now, you don't have to worry about death spirals with those individual insurance pools (as a whole, although one insurance company may still be more affected than another) because the pool is really everyone in the nation/state/region/etc.
1a) Employers won't like giving up the tax breaks they currently receive for offering the benefit, or they'll prefer to take that money and give it to the shareholders or executives, while I would rather that money be given directly back to the employees to help them purchase the insurance they now are no longer receiving from those employers. So I would phase out the tax breaks: the tax breaks are still available to companies for a few years after implementation, but they have to prove the money they would have spent on insurance is being given back to the employees. After a few years, once a new "normal" has been established for employee compensation, you can begin to phase out these tax breaks.
1b) With EVERYONE now needing to buy insurance on the individual market, you end up with coverage that isn't dependent on you being employed, and instead can take your same coverage with you whenever you change jobs (subject to your chosen insurance company's geographic area of operation). And with so many more people buying individual insurance, the insurance market place will need to be able to handle the traffic. (remember the fiasco with the ObamaCare website when it first went live? We don't want a repeat when everyone in the country is going to be dependent on it.)
1c) It's probably not my preference, but I guess I would be okay with offering a public insurance option as part of this approach. In areas that have few choices available for purchasing individual insurance, a public option can help provide a backup. I need to give it some more thought about how this could work such that you don't end up with insurance companies pricing all of the sick people onto that public option and trying to keep only the healthy people, or vice versa (all of the healthy people going to the public option and leaving all the sick people on private insurance).
1d) Allow the insurance companies to offer a wider variety of benefit plans. I'm not talking about providing options that don't cover maternity services or mammograms. Instead, I'm talking about allowing companies to sell high deductible health plans for people who may want a lower premium in exchange for potentially paying a higher out-of-pocket amount when they do receive services. The plans will all pretty much cover the same services, it will just be a matter of the out-of-pocket amounts involved.

2) There needs to be some sort of reform for hospitals, and the relationship between hospitals and doctors within a community. I've toyed with the idea of nationalizing the hospitals, so you don't have to worry about them becoming profit centers, but that's socialization I'm not willing to let happen to the insurance companies so I'm not really willing to let happen on the hospital side either. But I would like to see some way where the hospital is incentivized to help keep its community healthy, even when that means that community will not be going to the hospital as much and they won't be making as much of a direct profit. I know there are some initiatives out there surrounding this idea, and I've read some of them in passing, but haven't spent too much time looking at them in detail.

3) Malpractice reform.

4) Medical training reform. Not only look at removing or adjusting quotas for medical school attendance in an effort to increase the number of doctors, but look at responsibilities for nurses, physicians assistants, nurse practitioners, etc., in an effort to help provider more, valid, safe, lower-cost options for receiving routine care.

5) Pharmaceutical reform. I'm all for drug companies recovering the cost of their investments, but the recent price gouging of AIDS drugs and EpiPens highlights some loopholes in the current system that can be addressed to help keep drug costs reasonable while still allowing the pharmaceutical industry to make a reasonable profit.

There are plenty of other areas I want to get into, but this is already well past TL/DR length, and I need to get back to doing actual work.

[Zen]

Well, I evidently have been the victim of drug company price gouging in the past. I just got a mailing informing me that I am eligible to join a class action law suit against the makers of Provigil, one of the drugs I have been taking for several years. Evidently they delayed the release of the generic form of the drug for quite some time and lost the suit, to the tune of a $35 million settlement. Now I need to get records of how much I paid for the drug between June, 2006 and April, 2012 so I can submit a claim and have a shot at getting a share of that $35 mil... Considering that it was a tier 3 drug and I bought it every month (at a %50 copay per month) for many of the years in question, I hope to see some cash back...

[Tahlvin]

Interesting about why US healthcare costs so much.

[Tahlvin]

I'll add that I found that a very interesting podcast. They start off talking about how the ACA focused on health insurance and getting people covered, but didn't really focus controlling costs of the healthcare services being provided, so costs (and insurance premiums in turn) are continuing to rise at rates well above general inflation. They then talk about many of those cost areas, like pharmaceuticals, hospitals, etc. I found it very interesting and thorough, much better than the typical fare nowadays that just calls for single payer insurance without considering all of the other areas that are contributing to high costs and waste.

[Phoebe]

I want to listen to it but it's already in line behind this weird Nerd Pride podcast I sometimes listen to. However, IT SHALL HAPPEN at some point because this sounds really interesting and edifying. And everything else going on is so mysterious and crazy that maybe this is one thing I could learn something useful about, public policy wise.

[Tahlvin]

Incidentally, the second episode of the previously mentioned podcast was posted on 4/12, being an interview with the author of the book they discussed in the first episode. I've downloaded it but haven't listened to it yet. It's not something I want playing as background noise, but want to wait until I have some time to actively listen to what is being discussed.

[El Jefe]

I'm terrified to see what I'm going to pay in tax penalty next January. For a single month without insurance in 2016, it was almost $90. I'm already on month four of no-insurance this year. Though my income may be lower this time around, one hopes. And even an extremely limited insurance policy on the market was coming out near to $250 a month for me.

It's the fucking Wild West out there.

[Tahlvin]

I'm listening to the second part of the podcast, and the author had a really good comment that boiled down to: we tend to get mad at the insurance company for not reimbursing us or not covering a particular drug/service, but what we really should be asking is why the service/drug costs so much in the first place. It was mentioned particularly with regard to prescription drugs, where she said an inhaler that costs $50 in France, costs $300 in the US. She mentioned someone she interviewed who paid for their vacation to France by picking up their supply of inhalers while they were over there.

[Tahlvin]

An interesting example quoted in the podcast about the problems with drug patents. She talked about a drug that had been around for a hundred years or so, that was used to treat gout. It had never been tested against the FDA standards, however. So the FDA offered 3 years' exclusivity for the drug to any manufacturer that tested those older, existing drugs against the current FDA standards. One company did so for the gout drug, and once it had passed the tests, the cost of the drug skyrocketed from I think 10 cents per pill to about $5 per pill.

The same thing applied to Mike's pill (listen to the latest podcast episode) that's 3 drugs combined in a single pill. To the system as a whole, it would be better for people to be prescribed the three individual drugs. But by combining the 3 drugs into a single pill that's patented separately, and then incentivizing people to get the more expensive combined drug by giving a nice coupon, the drug company makes more money than they would on the three separate drugs that are just as effective. And there's that perverse incentive to Mike to choose that drug: with the benefit of the coupon, it's cheaper for Mike personally to purchase the drug that's actually more expensive to the healthcare system as a whole.

[Zen]

I have one thing to say... The bastards!

[bralbovsky]

You know it's a bad idea when congress exempts itself from having to follow it.

[Phoebe]

Well, in the month since the last comment, no progress on explaining why the hell people with a preexisting condition should have to pay lots more for their insurance, as if they were just really, really bad drivers who didn't deserve to have coverage for a car without paying a massive premium. If that's how we want to run things, then let's at least have no pretense, like whichever Congressman was saying the other day that people who get sick just ain't living right. Fuck 'em, right? Is that some kind of social Darwinism or more like God judging those stupid enough to be both poor and sick? Who knows, who cares. All I know is that the amount of money my own Mother had to pay in exorbitant premiums over the years is the amount of money I'm willing to kick in to 2018 elections.